By Man Mohan Mehndiratta, MD, DM (Neurology), FAMS, FRCP

Figure 1. International speakers on the occasion of IAN Conference Oct. 24-27, 2013: Upper panel from left to right are Robert H. Brown (USA), Marco T. Medina (Honduras), Olivier Dulac (France), Shuu Jiun Wang (Taiwan), Page B. Pennell (U.S.), Shri K. Mishra (U.S.), Beom S. Jeon (South Korea) and Keun Hwa Jung (South Korea). Lower panel from left to right are Vijay Sharma (Singapore), Barry Snow (New Zealand), Neeraj Kumar (U.S.), Martin J. Brodie (Scotland), William Carroll (Australia) and Bhupendra O. Khatri (U.S.).

The Indian Academy of Neurology (IAN), with its primary objective of imparting education, coordinates various activities that support and supplement formal neurology education. It has been instrumental in organizing various national and international conferences, workshops and Continuing Medical Education (CME) programs with national and international outreach programs¹.

Professor Marco T. Medina, professor of Neurology from Honduras was one of the faculty invited as part of this outreach program. Other invited international faculty members were Beom S. Jeon, vice president of the Asian Oceanian Association of Neurology; William Carroll, vice president of the World Federation of Neurology; Robert H. Brown, president of the American Neurological Association; Shri K. Mishra; Bhupendra O. Khatri; Neeraj Kumar and Page Pennel; J. D. Khandekar (USA); Barry Snow; Olivier Dulac and Martin Brodie. (See Figure 1.) These academic outreach programs foster critical and analytical thinking, professional and experiential learning and promotes research^2,3. It has an advocacy subsection convened by Man Mohan Mehndiratta and ably assisted by other committed members of IAN — Apoorva Pauranik and Lakshmi Narsimhan. It had been their sincere endeavor to improve the status of public awareness, education and care in India. This subsection organizes workshops to train the members in skills, organizes the neurology quiz, neurology education courses, public awareness and education series, CMEs and camps. Hence, it streamlines and disseminates authentic and comprehensive outreach public health education.

Like every year, the 21st Annual Conference of Indian Academy of Neurology, the IANCON2013, was held at Indore Oct. 24-27, 2013. It was hosted and organized by the Department of Neurosciences, ChoithramHospital and Research Centre and Neuro Club Indore. The conference featured the major breakthroughs and developments in the field of neurology — from clinical practice to research and technology and was attended by renowned national and international faculty and approximately 1,000 delegates. It included a highly informative and interesting scientific program starting with CME on neurological manifestations of systemic diseases, which addressed a wide range of conditions such as nutritional deficiencies, SLE and antiphospholipid antibody syndrome, liver disease, pregnancy, lymphoma and leukemia and small vessel disease. This was followed by symposia and seminars. The theme of one of the symposia was neurotechnology and e-learning, which was chaired by Mehndiratta and Medina from Honduras. Both technical and clinical perspectives regarding the benefits, challenges and limiting factors of developing robotics in neurorehabilitation were discussed. The integration of e-learning in traditional learning was emphasized.

Man Mohan Mehndiratta

Four orations were presented and the Presidential Oration was delivered by Mehndiratta. His presentation was titled “My Journey Through Indian Academy of Neurology and Academy’s Past, Present and Future.” He portrayed the establishment of the IAN, his 14 years of journey in the academy, growth of IAN in terms of academic activities such as conferences, public education and awareness programs and official publications both online (website) and offline (newsletter, reviews in Neurology, Journal- Annals of Indian Academy of Neurology). According to his foresight, the way forward for IAN includes collaboration and synergy, young talent recognition and continental and intercontinental outreach.

William Carroll, vice president of World Federation of Neurology, also graced the occasion and presented his oration on demyelinating diseases and challenges. Another interesting symposium focused on the diagnosis and management of cerebrovascular and neuromuscular diseases using point of care neurosonology.

For the first time in the history of IAN, an Asian and Oceanian Association of Neurology (AOAN) symposium was held in which one of the speakers was Beom S. Jeon, vice president of AOAN from South Korea. He provided valuable insight into how genetic disorders present in dystonia.  He also participated in the workshop on videos in clinical neurology. To encourage young neurologists, a paper presentation competition was held, and first, second and third positions were awarded.

A high point of this conference like earlier years was clinicopathological conference (CPC) on a case of fever, rapidly progress altered sensorium, raised intracranial pressure and seizures. The clinical discussant suggested the possiblity of Balamuthia granulomatous amebic encephalitis (GAE) and was confirmed as Balamuthia mandrillaris encephalitis on histopathology.

In the executive committee meeting, Robert H. Brown, president of the American Neurological Association (ANA) was invited to discuss the logistics to foster collaboration of ANA and IAN, which would be really helpful in achieving intercontinental educational outreach.

Looking ahead, IAN will continue to support the neurologists through its key functions, mentor young neurologists and provide opportunities for research. It will continue to develop more outreach initiatives to prepare students and practicing neurologists for academic excellence¹.

Mehndiratta is the director, professor and department head, Department of Neurology, JanakpuriSuperspecialityHospital, New Delhi-110058. He may be contacted at mmehndi@hotmail.com.

References

1. IndianAcademy of Neurology. Available at http://www.ian.net.in/index.html. Assessed on Nov. 8, 2013
2. O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007 Oct 17;(4)
3. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD.Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009 Apr 15;(2)

By Sarah Matteson Kranick, MD

Sarah Matteson Kranick

A recent study asked medical students and internal medicine residents to rate eight medical subspecialties with regards to the students’ feelings of competency and perceived difficulty.  The 150+ respondents identified neurology as the specialty in which they had least knowledge  (p<0.001) and was most difficult  (p<0.001).  [Winchuk AV BMC Medical Education 2010]

Similar studies in Europe and elsewhere have led to much consternation in the medical education literature over an emerging epidemic of “neurophobia.”  The demand for neurologists is predicted by the Workforce Task Force of the AAN to overtake supply by 2020, making “neurophobia” not just a problem for academic neurologists, but for all of primary medical education.  Primary care doctors will be increasingly called upon to triage, diagnose and treat neurological disorders at a time when subspecialization is increasingly common among neurologists.  How do we prevent “neurophobia” and increase the number of neurophiles among all of our medical students and medicine resident rotators?

The new edition of “DeJong’s The Neurological Examination,” by William W. Campbell, will appeal to neurophiles.  It has been modernized in many ways — the four-color edition is much easier on the eye, for one thing.  There are more images accompanying the text, with clearer photographs and MRIs to supplement the clinical vignettes.

The text has been reorganized somewhat, but still follows the general neurological encounter as most of us practice it.  This book is longer than the prior edition by almost 200 pages, but the expanded material is primarily clinical in nature, and the neuroscience underlying these observations remain mostly the same.  Most of us in practice will appreciate the balance of anatomy and pathophysiology here, as we are typically consulting such texts when we have just seen a patient with bilateral cortical ptosis, for example, and we are trying to remember whether supranuclear cortical control of the levator muscles has a left or right predominance.  This is the sort of question Campbell answers for us time and time again, with a concise description of the anatomy involved.  The “voice” of this textbook will remind you of a favorite professor from residency, and makes me envious of Campbell’s students at USUHS.

Throughout this edition, links have been inserted to various videos of the neurological exam and clinical examples of abnormal neurological signs.  Having the Kindle edition would certainly make these (hyper)links easier to use, although some reviewers on Amazon have noted that the Kindle edition makes viewing tables less ideal.  Unfortunately, after typing in four examples of links from the print edition, I found non-working videos each time.  Future editions would benefit from a webpage devoted to accompanying videos, or a DVD included in the print version.

Frequently DeJong’s is described as a book for residents, fellows or practicing neurologists.  I agree that the level of detail is likely too much for medical students, and that basic neuroscience must be mastered before attempting to understand clinical neurology.  This textbook, however, can play an important role in medical education at all levels.

For many of us neurophiles, it was the detection of some abnormal neurological sign in a patient we saw as medical students that started our lifelong interest in neurology.  In the short span of a four-week clinical rotation, we cannot expect every student to have enough patient encounters to prevent neurophobia.  Showing them how we practice the neurological exam, and what resources we use to put abnormal findings into context, like this text, may break down some of the intimidation that surrounds our specialty.

Kranick is chief of Neurology Consult Service,  National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md.

Participants in the web-based program in Cameroon.

Due to rapid demographic changes, the prevalence of Parkinson´s disease (PD) is increasing in sub-Saharan (SS) countries.¹  In contrast to developed countries, evidence suggests that most patients with PD are underdiagnosed and untreated, with markedly increased mortality and shortage of qualified personnel.²  In the last years, there has been renewed interest from the World Health Organization, telecomunications companies and medical associations about the use of telemedicine in Africa.³

To help increase access to care and to train providers around the world using technology, the International Parkinson´s disease and Movement Disorder Society (MDS) has sponsored pilot projects in care and education that can lay the foundation for reaching the majority of people with PD. In this regard, a telemedicine program for health providers has been developed at Hospital Laquintinie in Douala, a 3 million inhabitants city of Cameroon.

The course is a web-based program that will provide participants with access to specialized education in the field of movement disorders, which is currently unavailable in their region. Local neurologists and professors at the University of Douala, including Jacques Doumbe, MD, chairman of the Department of Neurology (Hospital Laquintinie), and Erero Njiengwe, PhD (University of Douala) have significantly contributed to the implementation of this course at Hospital Laquintinie in Doula, Cameroon.

The course consists of 12 lectures over the course of a year, which will connect participants with experts in the field of movement disorders using live video, slides, chat and audioconferencing.  The participants will have the opportunity to receive MDS membership and its benefits, including special education to certify them to use the MDS rating scales.  Two courses have been launched — one designed for doctors (neurologists, neurology residents, primary care and internists) and another one for other health professionals (nurses, physiotherapists and psychologists).

The course will be taught by professors from Hospital Universitario de Burgos, Hospital 12 de Octubre, Hospital Clinico San Carlos, Hospital Sant Pau and Hospital Central de Asturias all from Spain; Rush University Medical Center, Columbia University, Rochester University, all in the United States, Parkinson Victoria Association, Health Sciences University all in Australia,Hospital Universitario Asturias, Spain,  North Tyneside General Hospital in Great Britain and Hospital Galway and Parkinson Galway Association in Ireland. The main objectives of this pilot telemedicine education program will be to analyze the feasibility and adherence from participants, as well as satisfaction of users.

However, telemedicine for PD strategy development in Africa is challenging.  It is still expensive, and most of the SS countries have inadequate and communication technologies infrastructure, which creates difficult implementation and little access to the population. Telemedicine also needs to demonstrate success and sustainability, and this type of initiative has to survive beyond the end of the initial funding period.  Therefore, networking provides opportunities to spread the cost of infrastructure of telemedicine development between the local governments, business, foreign education providers and health sectors; therefore the cost burden should not be borne by just one sector.  Telemedicine for PD should be recognized to remove or at least mitigate the barriers that society and physical geography imposes, especially rural areas in Africa, and to be culturally appropriate if they are to be adopted and sustained.

References

1. Dotchin CL, Msuya O, Walker RW. The challenge of Parkinson’s disease management in Africa. Age Ageing 2007;36:122-7.
2. Dotchin C, Walker R. The management of Parkinson’s disease in sub-Saharan Africa. Expert Rev Neurother;12:661-6.
3. Scott RE, Mars M. Principles and framework for eHealth strategy development. J Med Internet Res. 2013 Jul 30;15(7):e155. doi: 10.2196/jmir.2250.

Organizers of the neurology training: Albert Akpalu (left), Korle Bu Teaching Hospital in Accra, Ghana, and Roberto Cilia, Parkinson Institute, Milan, Italy.

This course was jointly funded by the Movement Disorder Society (MDS) and the World Federation of Neurology. Additional co-sponsors were the Fondazione Grigioni per il Morbo di Parkinson (Italy) and the Society of Worldwide Medical Exchange (U.S.). This was the first neurology course designed for medical doctors who are not specialized in neurology. It was also open to neurologists interested in training in the field of movement disorders and dementia.

Participants were invited from throughout West Africa. Thirty-six participants attended the course, from Ghana (24), Nigeria (6), Sierra Leone (3), Gambia (2), and Cameroon (1).

The international faculty consisted of 16 international and local members, including neurologists, geriatricians, nurse specialists, a neuropsychologist, a physiotherapist, a nutrition specialist and a general practitioner from rural Ghana. The opening ceremony included guests such as the representative of the Minister of Health and of the nursing system in Ghana, the Italian Ambassador in Ghana, the chairman of Internal Medicine Department of the Teaching Hospital in Accra.

The course was run in English and included slide presentations and practical sessions with assessment of patients. Slide sessions focused on Parkinson’s disease (PD), dementia and other neurodegenerative disorders, covering epidemiology, diagnosis, pharmacological and non-pharmacological therapy. For the practical sessions with patients, participants were divided into small groups of five to six each, under the guidance of a faculty member, aiming to teach how to perform a neurological examination, neuropsychological scales screening for global and frontal-lobe cognitive functions and examples of physical therapy focused on gait and balance. Twelve patients attended these sessions, including PD, Lewy body dementia, Alzheimer’s disease and spino-cerebellar ataxia. In a session titled Bring Your Own Patient,” participants presented a patient from their own clinic and discussed with faculties the most relevant diagnostic and management challenges.

There were joint sessions with the PD Nurse Specialist Course, organized by Richard Walker (chair of the MDS Task Force on Africa).

Doctors and nurses had the opportunity to interact and share experiences about caring for patients. In particular, we included a Beyond the Neurologist session, dealing with the importance of a multidisciplinary approach to patients, especially in settings where medications are limited.

Educational material has been prepared and released for this course, including basic information about motor and non-motor features of PD and/or dementia. These booklets were drafted by different health care professionals (nurses, nutrition specialist, physiotherapists, neuropsychologists) and were full of pictures and photographs to be suitable for patients and caregivers with low education.

The course was a great success and participants’ feedback was positive in large part due to the practical sessions with patients and the interactive sessions. Each participant was given a DVD including all the slide presentations of the course, the UPDRS and the cognitive screening scales, the two educational booklets and photographs of the course. An email list was created including all the participants as well as the Italian and Ghanaian faculty, to share information and help in challenges of everyday clinical practice.

One of our aims was to make this course an opportunity to boost the education in the field of neurodegenerative disorders in developing countries. We promoted two initiatives:

• The entire course was professionally videotaped to make it available online.
• We provided two travel grants for the MDS events in 2014, the International Congress in Stockholm and the MDS summer school.