Travel can be illuminating. But perhaps none more so than the professional journey of Dr. Charles Hammond of Ghana who had to leave him home country for Child Neurology training in South Africa. Check out our Global Stuff You Should Know section to learn more about Dr. Hammond’s work as he settled back into “home” after years abroad.
The process of transitioning an adolescent with a neurologic condition from the pediatric to the adult health care system can be complex and seem daunting. It requires that the youth’s care team, including both the pediatric and adult neurologists involved, be aware of the medical, legal and financial implications of this transition and be able to use this information to support and guide the youth during the process. A smooth transition of care is likely to reduce youth and caregiver anxiety, prevent gaps in care, encourage youths to better understand and self-manage their own medical condition(s) and empower adult neurologists to feel more comfortable in taking care of young adults.
A challenge for the primary care medical home model (PCMH) is incorporating care from specialties. In this study, Elrashidi et al explored the impact of integrating a neurologist into the Mayo Clinic PCMH by comparing aspects of care delivered by the integrated neurologist with matched visits from the pre-integration time period. The integrated neurologist worked 0.6 FTE, had a staff of 3 FTE registered nurses, 3 clinical assistants, and a specified work plan — 3-4 scheduled patients per half day, in addition to curbsides, e-consults, follow-up, and additional acute same-day consults. Over a 12-month period of patient follow-up, patients seen by the integrated neurologist had fewer subsequent neurologist visits (0.62, p=0.001), EMGs (OR 0.64, p=0.009), and brain MRIs (0.60, p<0.001), but not total subsequent outpatient visits (0.92, p=0.21), ED visits (0.83, p=0.20), or hospitalizations (0.96, p=0.83) compared with the pre-integration visits. The integrated neurologist also did not lower the time to neurologist appointment (p=0.83), despite presumably reducing referrals because of curbsides and e-consults.
Burn-out is a phenomenon consisting of emotional exhaustion, feelings of cynicism/detachment, and a sense of being ineffective at one’s work, that threatens the well-being and safety of both physicians and the patients they treat. It is known to be a harbinger of work/home conflicts, health problems, and suicide among physicians.
In this issue of Neurology, Rubin and colleagues report disconcerting data from their analysis of the Women’s Interagency HIV Study database. In longitudinal assessments of cognitive and motor function in women with and without HIV infection, even among women with continuous viral suppression HIV-associated differences were evident. Perhaps even more disturbingly, in some domains women with continuous suppression performed more poorly than those with HIV who were not suppressed.
A newly published systematic review and meta-analysis in Neurology looks at the complications of sickle cell disease in Africa. In an accompanying editorial, Dr. Ralph Green and I consider the unmet challenges of these neurologic complications. As we note in the editorial, “Sometimes an important scientific report is more notable for what it cannot tell us than for what it can”.
Rossi and colleagues have published an interesting report on CNS inflammation in multiple sclerosis as it relates to anxiety and depression that may be more relevant to resource-limited tropical settings than one might imagine. Their paper makes an important contribution to the growing body of clinical data supporting the importance of CNS inflammation-induced anxiety and depression in persons with neurologic disorders. The potential for these psychiatric symptoms to serve as a possible warning sign of ongoing CNS inflammation warrants further study and the range of conditions for which this might be relevant is extensive.
Most in the ‘global know’ were dumbfounded in March when both President Trump’s “skinny” budget and the subsequent detailed one explicitly targeted the Fogarty International Center (FIC) for closure.¹
Health equity, as defined by The Robert Wood Johnson Foundation, means that “everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” The first step to obtaining equity in neurologic care is identifying health disparities, work that was recently undertaken by Altaf et al. This group of researchers analyzed the national state of equity in neurologic care using data from the 2006–2013 Medical Expenditure Panel Survey (MEPS), a nationally representative household survey, which queries medical conditions as well as medical expenditures, including outpatient and inpatient visits. After adjustment for socio-demographics, insurance status, health status, and self-reported neurologic diagnosis, the researchers found that black participants were nearly 30% less likely to see an outpatient neurologist and Hispanic participants were 40% less likely to see an outpatient neurologist compared to white participants.
For an interesting read, check out this report on Teleneurology from Saadi and Mateen detailing neurology referrals from Doctors without Borders delivered via a Collegium Telemedicus platform. As is so often the case with relatively new healthcare services, the report raises as many questions as it answers. If anyone reading this has utilized this system for MSF neurology consultation requests, it would be fascinating to better understand what the barriers are to referral given the relatively low numbers received. So few referrals were requested, I was reminded of the Peanuts cartoon with Lucy sitting all alone in her consultation booth awaiting the opportunity to give Psychiatry consultations for ¢5. Having provided these asynchronous telemedicine consultations myself, I must say my comfort level when offering advice to physicians located in regions where I have professional experience working and am very familiar with local clinical epidemiology, disease burden and health services capacity is quite high. In contrast, I am frankly uncomfortable when asked for my opinion on cases from regions where I lack these basic insights.