Without Borders Latest Interview: Dr. Benjamin Warf and Practice in Africa

Advances in Neurosurgical Capacity and Practice in Africa are improving options for patients while also informing care and offering training opportunities for neurosurgeons in the US. To learn more, listen to our interview with Dr. Benjamin Warf. Dr. Warf is the Director of the Neonatal and Congenital Anomaly Neurosurgery and Professor of Neurosurgery at Harvard Medical School. Early in his career, he moved his family to Uganda to direct a neurosurgical hospital for children funded by CURE. In 2012, he was awarded a MacArthur (‘genius’) Fellowship.

Fumbled Priorities and Lost Perspectives: Epilepsy in LMICs Today

Three cheers for Dr. Mamta Bhushan Singh whose candid editorial in the November issue of Seizure really sums up the problems of epilepsy research and care in the developing world today. 1  Such a maddening paradox—70% of epilepsy cases would respond to basic treatment, if provided. And rather than expending efforts to assure we put systems in place to roll out sustainable care to the masses, we in the global epilepsy arena continue to focus most of our attention and resources on the 30% of patients with treatment resistant epilepsy. This approach might make sense in developed settings, but certainly not in low and middle income settings where the treatment gap really hasn’t budged in more than two decades.

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Another recipe for improving global neurology for US trainees—this time with a dash of ACGME-flavored core competencies

An anthropologist-friend some years ago described the average international student elective as “an experience of inflicting the unprepared upon the unsuspecting.” Thankfully, as US global health programs have expanded in number with many becoming formally incorporated into existing training programs, a growing body of knowledge and academic thought about what should be included in a global neurology curriculum is starting to emerge.1-4

Continue Reading “Another recipe for improving global neurology for US trainees—this time with a dash of ACGME-flavored core competencies”

In response to Establishment of Epilepsy Surgery in Peru

I read with some interest the description of the recent development of not one, but two epilepsy surgery programs in Peru. There are certainly laudable aspects of the work including that, as described, it represents a true transfer of technical and medical capacity and not a “mission trip” with external experts dropping in briefly to declare victory over disease.

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The World Health Organization’s First Edition Essential Diagnostics List: More aspirational than feasible

In May 2018, the World Health Organization (WHO) published its first edition of a “Model List of Essential in Vitro Diagnostics” (EDL) in which they detail those clinical diagnostic tests which should be (ideally?) available and at which level of healthcare facility. Clearly, developing this list was no small undertaking and WHO is careful to state that the EDL is “not intended to be prescriptive…rather country programmes should make the ultimate decision about [EDLs] selected”. Nonetheless, there are some paradoxical recommendations hard to reconcile with realities. For example, the primary health care facility is delineated as:

“Primary health care: Health centres, doctors’ offices, health posts, outreach clinics. Typically, self-testing and rapid diagnostics tests are available, but there are either no laboratories, or small laboratories with trained health”

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What’s a picture worth?

In the world of TB, Tai et al.1 assessed the sensitivity and specificity of brain MRI for diagnosing CNS tuberculosis in Malaysia. They compared imaging in patients presenting with a meningoencephalitis who had TB confirmed by cerebrospinal fluid studies (PCR or AFB) and/or by tissue examination at autopsy to the MRI findings of patients with meningoencephalitis but not TB looking for what they termed “classical” TB imaging abnormalities which included—

  • Basilar enhancement
  • Hydrocephalus
  • Basal ganglia or thalamic infarcts
  • Tuberculomas
  • Vasculitis/vasospasm evident on MRA

They found that 89% of people with TBM had ≥ 1 classical MRI finding compared to only 4% of patients with other meningoencephalitides. Their study population was largely HIV uninfected (only 7% HIV positive). There would be significant value to determining if the excellent sensitivity and specificity of imaging in this population holds true for people with HIV.

  1. Tai MS, Mohn Nor, H., Rahmat, K., Viswanathan, S., Abdul Kadir, A., Ramli, N., Abu Bakar, F.K., Mohd Zain, N.R., Abdullak, S., Yap, J.F., Shaheed, J., Ng, B.S., Rafia, M.H., Tan, C.T. Neuroimaging findings are sensitive and specific in diagnosis of tuberculous meningitis. Neurology Asia 2017; 22(1): 15-23.

 

What’s Hot: Immune-mediated neurologic disorders

Immune-mediated neurologic disorders has been a hot and rapidly evolving topic in high income setting such as the US for the past few years. Now there is a burgeoning body of evidence suggesting that immune mediated phenomena deserve more attention in tropical setting as well.  In 2017, Johnson et al. discovered a leiomodin-1 autoantibody in the sera and CSF of patients with nodding syndrome that may be a result of Onchocercal volvulus (OV) infection. OV is the cause of River Blindness and has long been associated with Nodding Syndrome though direct infectious links have been ruled out.1 Also in 2017, Neurology published a report of Post Malaria Neurologic Syndrome (PMNS) in a patient found to have NEUREXIN-3a2 antibodies and another case report of PMNS associated with anti-voltage-gated potassium channel antibodies.3 PMNS has been previously described primarily in adults and involves neuropsychiatric manifestations, confusion or coma, and seizures, but pediatric cases have also been reported.4 In malaria endemic regions, acute febrile pediatric illnesses with seizure and coma for which no underlying etiology can be identified is a not uncommon clinical conundrum. One has to wonder what the full spectrum of PMNS might entail.

  1.  Johnson TP, Tyagi R, Lee PR, et al. Nodding syndrome may be an autoimmune reaction to the parasitic worm Onchocerca volvulus. Sci Transl Med 2017; 9(377).
  2. Costa A, Silva-Pinto A, Alves J, et al. Postmalaria neurologic syndrome associated with neurexin-3alpha antibodies. Neurol Neuroimmunol Neuroinflamm 2017; 4(5): e392.
  3. Sahuguet J, Poulet A, Bou Ali H, Parola P, Kaphan E. Postmalaria Neurologic Syndrome-Autoimmune Encephalitis With Anti-Voltage-Gated Potassium-Channel Antibodies. Ann Intern Med 2017; 167(1): 70-1.
  4. Kernan RJ, Gavin PJ, Butler KM, Leahy TR, Lynch B, Leonard J. Expanding the Spectrum of Post-malaria Neurologic Syndrome in the Pediatric Population. Pediatr Infect Dis J 2018; 37(5): 499-500.