December 2014 – Page 2

WFN Training Centers

Wolfgang Grisold

By Wolfgang Grisold and Steven Lewis

A worldwide concept for regional training

The mission of the World Federation of Neurology (WFN) is to foster quality neurology and brain health worldwide by promoting global neurological education and training. The WFN Education Committee has developed a concept paper to define the standards and requirements for WFN Training Centers worldwide. The purpose is to establish worldwide standards of neurological care and at the same time improve local training in neurology.

WFN Training Centers will provide excellent training in neurology regionally in all parts of the world. To be accredited by the WFN, centers must be public, openly accessible university centers. Neurology must be a department on its own, closely connected to related fields, such as neurosurgery, internal medicine, psychiatry, radiology and neuropathology.

Departments should have a defined structure of experience in general neurology, dealing with the most common neurological diseases worldwide, and also addressing local neurological needs. Training must be performed in inpatient and outpatient services. In addition, electrophysiology, neuro-ultrasound and CSF analysis should be available in the department. The objective of the training course should be the independent, unsupervised practice of neurology by the trainees after the termination of their training.

The center needs to provide the WFN with a detailed plan of the training, the teaching staff and the availability of departmental facilities and structural facilities for the WFN trainees, including a detailed description of housing and accommodations, legal issues, working permit and insurance.

Prior to the establishment of a WFN Training Center, the center must follow the accreditation process set by the WFN. This includes the submission of a formal application and detailed report about the center, written and face-to-face interviews with center staff and a site visit by representatives of the WFN.

The WFN, as a charity registered in the U.K., will only grant accredited status to a center after a thorough examination. The WFN expects that the Training Centers will conduct their programs in a responsible and economic way, in line with the WFN’s charitable aims.

Training Centers make regular reports to the WFN about the development of the trainees and confirm the end of training or other agreed milestones. WFN Training Center accreditation is for a period of two years and can be renewed.

Positions for future trainees at WFN Training Centers will be announced on the WFN website and on social media. The selection of candidates will be made by a committee composed of local/regional representatives and members of the WFN Education Committee.

Visit the WFN website for more information about WFN Training Centers.

Neurodevelopmental Disorders in India: From Epidemiology to Public Policy

Donald H. Silberberg

By Donald Silberberg, MD

Epidemiologic studies address many needs, ranging from contributing to the understanding of disease pathogenesis to stimulating the development of public policy that addresses health needs. A successful example of the potential for new information to stimulate public policy is the nationwide study of the prevalence of neurodevelopmental disorders in India, carried out by members of the International Clinical Epidemiology Network (INCLEN).

When I suggested the study 10 years ago, almost no data was available for India or for neighboring countries. After successfully obtaining funding from the U.S. National Institutes of Health (NIH), the voluntary health organization Autism Speaks and The Government of India, Dr. Narendra Arora, then the newly appointed executive director of INCLEN, hosted meetings in New Delhi in order to develop the study.

The investigators included, in addition to Dr. Arora, MKC Nair, director of the Child Development Center, Medical College Thiruvananthapuram, Kerala; Sheffali Gulati, pediatric neurology chief, All India Institute of Medical Sciences, New Delhi; Vinod Bhutani, neonatologist, Stanford University, Palo Alto, California; Maureen Durkin, anthropologist/epidemiologist, University of Wisconsin, Madison; and Jennifer Pinto-Martin, epidemiologist, School of Nursing, University of Pennsylvania. Dr. Arora wisely involved the National Trust, part of the Ministry of Social Justice and Empowerment, Government of India, a choice that undoubtedly contributed to our success in helping to develop public policy.

The main objectives of our research were:

To estimate the prevalence of Neurodevelopmental Disorders (NDDs) among children aged 2-9 years, among urban, rural, hilly areas and tribal communities in India
To gather data on risk factors for NDDs
To develop and disseminate screening and diagnostic methodology for India and other countries in which individuals with NDDs have been underrecognized.

The domains studied were: Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Intellectual Disability, Epilepsy, Learning Disability, Neuromuscular Disorders, Cerebral Palsy, Speech and Language Disorders, Hearing, and Vision Impairment.

Increasingly robust screening questionnaires were developed, expanding on the well-known “10 Questions” screen¹. More than 50 clinicians and social scientists contributed to the design and execution of the study. Analysis of the data derived from the original 39-question Neurodevelopmental Screening Tool (NDST) used in gathering data from 4,000 families from six regions of India revealed that optimal sensitivity and specificity was achieved by using only 11 questions.

The questionnaire that was finally used is described in several publications^2,3,4,5. Countrywide results (excluding tribal data) revealed that from 10 percent (hilly areas), 13 percent (urban areas), to 18 percent (rural areas) of children ages 2-9 years were found to have one or more NDD. The tribal prevalence was 4.96 percent, perhaps reflecting lower infant and child survival.

The study was supported by: NIH (USA) Grant R21 HD53057, MKC Nair (PI), J. Pinto-Martin and D. Silberberg (Co-PIs), S Gulati, Network Coordinator); Autism Speaks (USA); The National Trust (Government of India) and INCLEN. Importantly, the NIH funding was obtained via the Fogarty International Center’s “Brain Disorders Across the Lifetime” program. (See Dr. Donna Bergen’s article on page 4).

On the basis of the methodology and results, The Government of India has undertaken two initiatives:

Questions regarding disability were included for the first time in the 2011 Census of India.
A national program for screening, diagnosis and treatment of NDDs was launched in 2013, the Rashtriya Bal Swasthya Karyakram (RBSK; National Child Health Program). The program is funded with more than $400 million, in order to develop 630 centers for screening and subsequent care of those found to have a neurodevelopmental disorder. Activities to achieve implementation are under way in many regions of India.

This outcome serves as a case study of epidemiology as “translational research,” a term ordinarily used to describe the process of bringing research laboratory results to the bedside. Clearly, epidemiology can be used to serve advocacy, as we work to improve neurologic health in all regions of the world.

References:

1. Zaman, Sultana S., Khan, Naila Z., Islam, Shaheen, Banu, Sultana, Dixit, Shanta, Shrout, Patrick, and Durkin, Maureen. “Validity of the ‘10 Questions’ for Screening Serious Childhood Disability: Results from Urban Bangladesh.” International Journal of Epidemiology 19, no. 3, (1990): 613-620.

2. Juneja, Monica, Mishra, Devendra, Russell, Paul S. S., Gulati, Sheffali, Deshmukh, Vaishali, Tudu, Poma, Sagar, Rajesh, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and Inclen Study Group. “INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): Development and Validation.” Indian Pediatrics 51, no. 5 (2014): 359-365.

3. Mukherjee, Sharmila, Aneja, Satinder, Russell, Paul S. S., Gulati, Sheffali, Deshmukh, Vaishali, Sagar, Rajesh, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K, and INCLEN Study Group. “INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD): Development and Validation.” Indian Pediatrics 51, no. 6 (2014) 457-462.

4. Konanki, Ramesh, Mishra, Devendra, Gulati, Sheffali, Aneja, Satinder, Deshmukh, Vaishali, Silberberg, Donald, Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and INCLEN Study Group. “INCLEN Diagnostic Tool for Epilepsy (INDT-EPI) for Primary Care Physicians: Development and Validation.” Indian Pediatrics 51, no. 7 (2014): 539-543.

5. Gulati, Sheffali, Aneja, Satinder, Juneja, Monica, Mukherjee, Sharmila, Deshmukh, Vaishali, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Tudu, Poma, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and INCLEN Study Group. “INCLEN Diagnostic Tool for Neuromotor Impairments (INDT-NMI) for Primary Care Physician: Development and Validation.” Indian Pediatrics 51, no. 8 (2014): 613-619.

International Neurology Forum in Kazakhstan

By Aida Kondybayeva, MD

Aida Kondybayeva

For years, the World Federation of Neurology (WFN) has reached out to Kazakhstan and its neurology community. However, language barriers made it difficult to establish a connection. After a two-year effort by Prof. Daniel Truong and Saltanat Kamenova, with the valuable assistance of Aida Kondybayeva, the International Neurology Forum for Parkinsonism and Related Disorders was held in Kazakhstan. The forum was hosted by the Asfendiyaroy Kazakh National Medical University and was attended by more than 120 Kazakh neurologists.

Prof. Aikan Akanov, rector of the university, opened the forum by thanking the organizers and emphasizing the importance of the event for Kazakhstan. Internationally known speakers included Profs. Erik Wolters from the Netherlands, Truong from the United States and Carlo Colosimo from Italy. Speakers from Kazakhstan included Guram Pichkhadze from the Virtual Institute of Neuroscience, Saltanat Kamenova, chairwoman of the department of neurology at the university and Marat Asimov, chairman of the department of medical psychology.

All of the lectures were translated in real time for the audience. The topics discussed were broad and included the diagnosis, pathology and neuropsychology of

Opening statement of the International Neurology Forum by Prof. Aikan Akanov on Sept. 23, 2014, with Prof. Guram Pichkhadze, Erik Wolters and Daniel Truong.

Parkinson’s disease, tremor and dystonia, as well as the management of these disorders. In addition to the presentations, several workshops were offered, led jointly by Profs. Shelekov, Truong, Perlenbetov and Nurmagambetova.

The meeting was supported with a grant from the International Association for Parkinsonism and Related Disorders (IAPRD). All participants received a free textbook as a gift from the IAPRD. On the last day of the forum in her closing remarks, Prof. Kamenova noted the importance of this event for doctors and young neurologists of Kazakhstan and thanked Profs. Wolters and Truong for their noble mission in the development of the educational program.

Kondybayeva is with the Asfendiyarov Kazakh National Medical University.

A Continuing Journey: The Fight Against Stroke in India

Rohit Bhatia

By Rohit Bhatia, MD, DM, DNB

The stroke epidemic has arrived in India. While we were busy combating the scourge of infections and deficiency diseases, non-communicable diseases (NCDs) including stroke stealthily crept up on us.

With a population of 1.2 billion today and growing, India finds itself staring at a stroke epidemic (See “The Stroke Fact Sheet in India.” on page 8.) ^1,2. In addition to strokes due to conventional risk factors, cardio-embolic stroke due to rheumatic valvular heart disease, cerebral venous thrombosis, and strokes related to tuberculous meningitis still remain important causes of stroke, especially in the young Indian population. (See Figure 1.)

Figure 1. Types of strokes (arrows): (a) bilateral arterial infarcts in a patient with rheumatic heart disease and atrial fibrillation (b) venous infarct in a post-partum patient with superior sagittal sinus thrombosis (c) intracerebral hemorrhage in a hypertensive patient, (d) arterial embolic infarction due to large artery athersoclerosis and carotid stenosis (e) and (f) perforator artery infarction in patient with tubercular meningitis.

The recently published Prospective Urban Rural Epidemiology (PURE) study from 18 low-, middle- and high-income countries showed that incidence of major cardiovascular disease was highest in low-income countries, despite the fact that these countries had the lowest risk-factor burden³.

Challenges in stroke care include a limited number of trained neurologists who are mostly urban, a large number of patients who are mostly rural, a lack of knowledge and awareness both about stroke risk factors and treatment in the general public and prohibitive cost of stroke care. There is a lack of uniformity and standardization of secondary and tertiary stroke care while availability of primary care in stroke is extremely unreliable. The stroke epidemic did catch us by surprise and in an unprepared state, but the situation is gradually beginning to improve and we are optimistic about the future. (See Figure 2.)

Acute stroke care has barriers, including recognition, pre-hospital delays, physician expertise, lack of ambulance services, cost of tPA and lack of critical care facilities. Although thrombolysis (using tPA) continues to be available only in urban private or academic hospitals, there has been a recent rise in the number of stroke patients getting the benefit of this treatment.

Figure 2. Recovering stroke patients at the Stroke Clinic, Neurosciences Center, AIIMS.

In the year 2009, 1,648 patients were thrombolysed, while in 2011, the number rose to 2,975 and a center in northwest India reported a four-fold increase in rates of thrombolysis². About 100 centers in India currently have facilities to provide intravenous thrombolysis, and the numbers are likely to rise with awareness and experience.

In the national capital region, the cost barrier is gradually being offset for eligible patients by the provision of free tPA by the government in state-run academic hospitals, including All India Institute of Medical Sciences (AIIMS), New Delhi. The National Program on Prevention and Control of Cardiovascular Diseases, Diabetes and Stroke⁴ (NPCDCS) launched in 2008 by the ministry of health and family welfare (See “Major Components of NPCDCS.”) addresses NCD prevention by risk reduction, early diagnosis and appropriate management through health promotion programs for the general population and high-risk groups.

Figure 3. Map of India showing the National Program on Prevention and Control of Cardiovascular Diseases, Diabetes and Stroke (NPCDCS Program), Government of India. Red dots indicate places where it is currently implemented. Stars indicate the Indian states⁴.

At present, the NPCDCS program is implemented in 100 districts across 21 Indian states, and it is expected to be rolled out in 640 districts by 2017 under the 12th five-year plan. (See Figure 3.) Developing and running dedicated stroke units in the face of the extremely limited health resources is a challenge; 35-40 stroke units currently exist, mainly in bigger cities and more often in private hospitals.

Improving Access to Stroke Care

Reaching out to remotely located patients remains difficult, and telestroke is recognized as a potential solution⁵. Telemedicine has been successfully used by the Indian Space Research Organization (ISRO) to meet the needs of remote Indian hospitals⁶.

The telemedicine network implemented by ISRO in 2001 presently stretches to around 100 hospital countrywide, with 78 remote rural/district health centers connected to 22 speciality hospitals in major cities, thus providing treatment to more than 25,000 patients, including stroke patients. (See Figure 4.) A major telestroke initiative has been taken up by the state of Himachal Pradesh (HP). Telestroke Management Program has been piloted for the first time in HP in collaboration with AIIMS. Under this program, 18 primary stroke centers are being set up in HP state hospitals, which have CT scan facilities. One hundred and twenty state doctors have been trained and six patients already have been successfully treated under this program. Success of this program will pave the path for comprehensive treatment of stroke patients in more parts of the country.

Research in stroke medicine is another area that has seen improvement with increasing national and international collaborative efforts and improved funding opportunities. The Indian Council of Medical Research (ICMR), Department of Biotechnology (DBT) and Department of Science and Technology (DST) of the Government of India have increased support for basic and clinical stroke research.

The WHO stroke STEPS I version 7 was tested in the Indian Collaborative Acute Stroke Study (ICASS). During 2002-2004, 2,162 acute stroke cases were identified in the study. Analysis of results confirmed that the incidence of stroke was rising with the advance in age. Presently, there are eight stroke registries based in various states of India. Each registry has independently set up a stroke surveillance system based on the WHO STEPS guidelines⁷.

Figure 4. Indian Space Research Organization (ISRO) telemedicine network⁶.

The National Stroke registry of the ICMR is being run by the National Center for Disease Informatics and Research, Bangalore, where staff members have started the process of collating data on stroke patients from institutions and individual specialists who have registered with the program. The Indian Stroke Prospective Registry (INSPIRE) is a large, multicenteric prospective pilot registry run by the division of clinical trials, St. John’s Research Institute, Bangalore, with the objective of determining etiologies, clinical practice patterns and outcomes of stroke in India.

By April 2012, the study had enrolled 5,301 patients from 49 cities in 19 states. Data from these registries will provide evidence on mortality and morbidity indicators in India, which could help plan an effective stroke management program. In collaboration with Erasmus University Netherlands, AIIMS has jointly launched a large cOHORT study comprising 15,000 people above the age of 50 in rural and urban populations to prospectively examine the causes of stroke and dementia in the Indian population. The Department of Biotechnology has generously funded this endeavor with INR 340 million.

Increasing Stroke Awareness

Education programs are being carried out by hospitals and stroke support groups especially around the World Stroke Day to educate and disseminate information on stroke⁸. Initiatives include patient awareness programs with lectures and interactions focused on stroke symptoms, the concept of “time is brain,” the need to reach a hospital early and preventive strategies to reduce stroke occurrence; banners, advertisements and write-ups in newspapers along with talk shows on TV and radio channels are also used.

Figure 5. Educational workshop on stroke conducted by Department of Neurology AIIMS.

Studies have shown that lack of physician awareness delayed arrival of stroke patients to a specialized center. CMEs, physician training programs and conferences are regularly held across the country emphasizing the need for recognition and timely therapy and to appraise doctors regarding the newer developments on cerebrovascular disorders. (See Figure 5.) The Indian Stroke Association (ISA) has been organizing a stroke summer school since two years ago to train junior neurologists and physicians.

The annual meetings of ISA are well attended with invited national and international faculty and deliberations on various aspects of stroke. The national guidelines for the management of stroke in India were developed with an aim to close the gap between best and pragmatic practice. A recent study from an academic hospital in North India observed that education to the emergency staff led to an increased rate of thrombolysis and shortened door to needle time. It is encouraging to see that students trained at academic centers are now promoting stroke awareness and timely treatment in smaller cities.

The Future of Stroke Care in India

We will never be able to treat every stroke in the country for a long time to come. So where should our emphasis lie? Preventing as many strokes as possible will probably be the best stroke care that we can provide. At present, many, if not most, strokes are a consequence of modifiable risk factors such as obesity, hypertension and smoking.

Spreading awareness on a war footing and reducing preventable strokes immediately is required. Implementation of mass screening has been recommended to reduce the burden of stroke through identification of people at high risk. Simple, practical and cost-effective measures such as identification and treatment of hypertension in the community will go a long way. Focus also should be on effective implementation, monitoring and evaluation of present stroke programs. A stroke prevented is a much happier situation than a stroke treated.

References:

1. http://www.sancd.org/Updated%20Stroke%20Fact%20sheet%202012.pdf. Stroke in India Factsheet (Updated 2012). Accessed September 6, 2014.

2. Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. Journal of Stroke. 2013;15:128-34.

3. Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, Bo J, Lou Q, Lu F, Liu T, Yu L, Zhang S, Mony P, Swaminathan S, Mohan V, Gupta R, Kumar R, Vijayakumar K, Lear S, Anand S, Wielgosz A, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Yusoff K, Ismail N, Iqbal R, Rahman O, Rosengren A, Yusufali A, Kelishadi R, Kruger A, Puoane T, Szuba A, Chifamba J, Oguz A, McQueen M, McKee M, Dagenais G; PURE Investigators. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med. 2014;28:818-27.

4. http://health.bih.nic.in/Docs/Guidelines/Guidelines-NPCDCS.pdf. Accessed September 5, 2014.

5. Srivastava PV, Sudhan P, Khurana D, Bhatia R, Kaul S, Sylaja PN, Moonis M, Pandian JD. Telestroke a viable option to improve stroke care in India. Int J Stroke. 2014 Jul 18. [Epub ahead of print].

6. http://www.telemedindia.org/isro.html. Accesssed October 4, 2014.

7. Bonita R, Beaglehole R. Stroke prevention in poor countries. Time for action. Stroke 2007;38:2871-2872.

8. World Stroke Day celebrations: report from India. International Journal of Stroke. 2009;4:231–232.

Additional professor: Pranjal Sisodia, MSc, PhD Scholar, Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India.

To correspond with the author, write to him at rohitbhatia71@yahoo.com.