Thursday, April 25, 2013

Infectious and Cerebrovascular Diseases in Peru

Shibani Mukerji
PGY-3, Partner's Neurology

As in many South American countries, Peru has a wealth of patients with neuroinfectious diseases.  In Lima, there appears to be  a disproportionate number of neurologists available to help with their diagnosis in comparison to the rest of the country.   Peru has 254 neurologists registered with the Peruvian Medical Association (approx. 1 neurologist per 119,980 people) and nearly 73% of them work in Lima.   

 Navarro-Chumbes et. alNeurol Int. 2010 June 21; 2(1)

The Instituto Nacional de Ciencias Neurologicas (INCN, is both an inpatient hospital with outpatient clinics that specializes in adult and pediatrics neurology.   I spent the majority of the last week in their infectious disease ward.  This ward has 28 inpatient beds and will typically be operating at near capacity.  In a sampling of 15 patients seen on a single day, 8 patients presented with seizures and headache due to Neurocysticercosis, 1 patient presented with loss of vision, seizure and headache due to a Tuberculosis granuloma, 1 patient presented with decreased consciousness and fever due to TB meningitis, 1 patient developed high grade fevers from presumed bacterial meningitis, 1 patient presented with headache and nausea/vomiting due to cryptococcal meningitis and diagnosed with AIDS, 1 patient with known HIV presented with seizure and diagnosed with presumed toxoplasmosis, 1 patient with headache and hemiparesis with likely glioblastoma multiforme and 1 patient with a multiple sclerosis flare with right arm and leg paresis (the unit cares for several noninfectious related diseases that are not vascular related).  The average age of this small cohort was 40 years old.
A.  Infectious disease ward at INCN.  All patients are in one ward separated by men and women.  
B.  Symptomatic patient with Racemose and intraparenchymal neurocysticercosis
The use of the lumbar puncture is hindered at times as most Peruvians fear invasive testing and need coaxing into performing the procedure.   At the INCN, most patients will have LP results but there is limited ability in obtaining gram stains, speciation, HSV PCR or other CSF diagnostic testing.  Clinicians rely primarily on the cell count and differential, chloride, lactate, total protein and glucose along with the clinical story to make their diagnosis.  They do not obtain opening pressure as they don't typically have manometers. In regards to imaging, the INCN does not have its own MRI at this time, but plans are currently ongoing.  Of note, an MRI brain costs ~$250 (US dollars) which has to be paid for entirely by patients.  

This past week, I also had the unexpected pleasure to visit Hospital Nacional Dos de Mayo in Lima ( with a fabulous neurologist, Dr. Fred Raul Jeri.  It is a hospital which serves adults and children and has most specialties including neurology.  Dr. Jeri initially trained as a psychiatrist and then switched to neurology.  He spent a year with the MGH neurology/neuropathology department, training under Dr. EP Richardson and Dr. Ray Adams.  His project was to assist in the definition of neuropathological definition of irreversible coma with Dr. Richardson, work later published in 1968.  A man in his 80s, he continues to see patients both as an inpatient neurology consultant and in his outpatient clinic, serving primarily HIV patients with neurological and psychiatric conditions.  The neurology department has clinical neuropathology rounds every Wednesday morning with interesting cases including last week's case of a woman with HIV who developed progressive weakness of her legs.  A chest xray revealed a cavitary lesion in the apex of her left lung which was eventually biopsied and ultimately diagnosed with thoracic actinomycosis which had spread to the vertebra resulting in cord compression.
One of the female general wards

Outside Hospital Nacional Dos de Mayo

Dr. Fred Raul Jeri in his clinic

In this past week, I have learned an extraordinary amount about the clinical presentation of neurological infectious diseases, particularly the art of diagnosing and treating Neurocysticercosis, tuberculosis and HIV-related neurological disease in the setting of limited availability and not always rapid diagnostic testing.  On my next blog, I will discuss some ongoing research in Neurocysticercosis.

I am grateful to the Partners Global Health Travel Grant, Partners Neurology Residency Program, Dr. Joseph Zunt and Dr. Hugo Garcia for coordinating and allowing me this amazing opportunity.  

Aaron Berkowitz
PGY-3, Neurology
Travel Grant: Neurology Education in Malawi

After two weeks on the wards of Queen Elizabeth Central Hospital in Blantyre, described in my blog entry below, the last two weeks have taken me to two very different contexts in Malawi.

I spent one week in the capital city of Lilongwe at Malawi’s only medical school. It was the week of the preclinical students’ neurology block.  As the lone neurologist in the country, I was asked to participate by giving lectures on stroke, epilepsy, neuropathy, meningitis/encephalitis, HIV-related neurologic disorders, coma, headache, and interpretation of head CT (which is available in Lilongwe). I also assisted in the evaluation of students’ clinical skills in an examination in which they performed neurologic examinations on patients and presented their findings.

Teaching at the medical school in Lilongwe

In teaching neurology here, I have realized that beyond participating in training non-neurologist physicians who will see a large burden of neurologic disease, a true achievement would be to inspire one (or several) students to train in neurology. I therefore emphasized in my lectures that 80% of the world’s 50 million epilepsy patients and nearly 90% of the world’s stroke deaths are in developing countries, and invited/challenged students to consider becoming the country’s first neurologist(s). The need is enormous- during this brief visit to the capital, I saw 10 patients with primary neurologic disease on the wards of Kamuzu Central Hospital, bringing my total number of consultations to over 40 in just a few short weeks.

The main entrance (left) and one ward (right) at Kamuzu Central Hospital in Lilongwe.

This past week, I traveled to the district hospital of rural Neno, a stark contrast to the cities and the cities’ large tertiary referral hospitals. It is here that Partners in Health/Abwenzi Pa Za Umoyo works with the Malawi Ministry of Health to support the district’s main hospital (about 80 beds) and a number of health centers in the region. One sharp turn off of one of the country’s main highways took us onto unpaved dirt roads shared with ox-drawn carriages.

The road to/through Neno (left) and one of the many villages in the district (right)

One focus of the Partners in Health/Abwenzi Pa Za Umoyo outpatient chronic disease programs is epilepsy. As mentioned above, 80% percent of the world’s epilepsy burden is in the developing world, likely due to increased incidence of CNS infections, head trauma, and perinatal complications. It has been estimated that as many as 90% of patients may be untreated in some regions of the developing world, leading not only to unfortunate morbidity and mortality due to uncontrolled seizures but devastating stigma. Neno is fortunate to have a brilliant clinical officer, Grant Gonani, with training in mental health, who sees both psychiatric and neurologic patients. I spent one morning with him in his mental health clinic learning how he cares for his epilepsy patients and how epilepsy is managed here with the three available medications whose supplies may fluctuate. While in Neno, I also had the chance to give a presentation on seizures/epilepsy care to the clinical officers and nurses, and lead a practical session with the clinical officers on refining their neurologic examination skills.

The district hospital in Neno (left) and the outpatient clinic patient waiting area (right)

My time in Malawi has gone by all too fast, and I am very grateful to have had the chance to learn from diverse settings: the two largest hospitals in the two largest cities, the medical school, and a district health center in a more rural region. The need for neurology here is enormous, and I hope that I can continue to return to learn and teach. In the interim, I hope to continue collaborations and consultations by way of the internet.

I am very grateful to the administrators, medical students, clinical officers, residents, and attendings in Blantyre, Lilongwe, and Neno for so warmly welcoming me to Malawi and for allowing me to participate in the care of their patients and in their educational activities. I look forward to returning soon. I was also fortunate to work with an extraordinary mentor here, Dr. Gretchen Birbeck, one of the pioneers in global neurology. I also again want to thank the Partners Global Health Travel Grant and Partners Neurology Residency staff - Vanya Sagar and Silviya Eaton - and program leadership - Dr. Tracey Milligan, Dr. Tracey Cho, and Dr. Martin Samuels- for supporting this work.

Tuesday, April 16, 2013

Aaron Berkowitz
PGY-3, Neurology
Travel Grant: Neurology Education in Malawi

Queen Elizabeth Central Hospital in Blantyre, Malawi is the country’s largest hospital, with over 1000 inpatients. As there is no district hospital in the vicinity, the hospital provides all levels of care from primary through tertiary care. It also serves one of the primary sites of medical education for medical students, residents, and clinical officers in training.


On the left, the recently built emergency department at Queen Elizabeth Central Hospital. On the right, mountains seen in the distance behind the hospital.

The main hallway (above) is reminiscent of Brigham and Women’s “Pike,” a seemingly infinite corridor with various ‘exits’ to the wards of the different specialties: medicine, surgery, pediatrics, obstetrics, hemodialysis, oncology, radiology.

One specialty, however, is not represented: neurology. In fact, there are no adult neurologists in the entire country of Malawi (there is one pediatric neurologist). The number of patients admitted for neurologic problems, however, is substantial, as would be expected at any tertiary referral hospital. In just under 2 weeks since arriving and working with only the internal medicine service (generally serving 150-200 inpatients), I have been asked to see 22 inpatients and 9 outpatients with primary neurologic symptoms/signs. In contrast to the usual elderly average age on a neurology service in the United States, the average age of patients I have seen so far has been 36. A few consults have been straightforward (e.g., stroke, neuropathy), but many have been mysterious constellations of symptoms and signs in young patients without clear explanation, and limited diagnostic testing to pursue a diagnosis and craft a treatment plan.

On the left, the entry to the Department of Medicine; on the right, one bay of the women's ward at QECH

When hearing the students and house staff present patients, one is struck by the fact that the first identifying statement for the patient (i.e., age, sex) always includes the patient’s HIV status, and this is presented even before the chief complaint. No presentation of a physical examination is complete without mentioning whether there are Kaposi sarcoma lesions. The prevalence of HIV/AIDS in Malawi is around 12%, and I have been told that 80-85% of the hospital’s patients at any given time are HIV positive. Of the 31 patients I have seen so far, 11 have been HIV positive. HIV and resultant opportunistic infections can affect any part of the nervous system at any stage of the illness from seroconversion to advanced AIDS, leading to complex diagnostic quandaries, especially in the setting of one or more additional systemic illnesses that may or may not be HIV-related.

The medicine department asked for visiting neurologists to come to teach students and residents as there are no neurologists in the country. I have truly enjoyed working with the extraordinarily enthusiastic students and housestaff. Given limitations in diagnostic testing (e.g., no basic chemistries, no CT scans), clinicians here are extraordinary bedside diagnosticians. Teaching how to use the detailed neurologic examination for localization and differential diagnosis in neurology is therefore a natural extension of the exceptionally astute clinical skills already deeply ingrained in the students and residents.

I also had the opportunity to teach the clinical officers staffing the emergency department. Clinical officers are the country’s first line of medical care at district hospitals, clinics, and emergency rooms, with training essentially analogous to a physician assistant in the U.S.

While my primary role here has been to teach, I have surely learned much more than I have taught, not only about HIV-related (as well as malaria and tuberculosis-related) neurologic disease and clinicial decision-making in the setting of limited diagnostic testing, but also about how to attempt to convey the essentials of neurologic clinical reasoning in different ways for non-neurologist practitioners at different levels of training practicing in different contexts.

I am grateful to the Partners Global Health Travel Grant and Partners Neurology Residency for supporting this work.

Wednesday, April 3, 2013

Emergency Ultrasound in Colombia - David Beversluis

GME Centers of Expertise Global Health Blog

David Beversluis MD MPH
Emergency Medicine PGY3
Characterizing Emergency Medicine in Colombia

Blog entry number 2! I'm quickly finishing up my time here in Colombia and will unfortunately soon need to get myself back to Boston and start up work in the hospital again. I've got a few days left though and spending as much of it on a sunny beach as possible.

The last 2 weeks have been filled with hospital visits and plenty of interesting work on the research phase of my elective. I finished my work in several Bogota EDs and then met up with the PI for my project, Dr. Christian Arbelaez (BWH EM attending), in the airport on the way to Medellin. We spent about 4 days working there, joined on the first day by my co-resident Christina Wilson, and then moved to Cartagena where we spent several additional days as a group visiting several hospitals and the university medical school. As I mentioned in my previous post we're working on two projects during this time here in Colombia. First, Christian, in his role as the ACEP Ambassador for Colombia is spearheading a project to characterize the EM system here in Colombia. This project will eventually result in a joint report with several Colombian EM colleagues describing the system in general and the state of EM residency programs in the country. For this project we're conducing site visits and focus groups at most of the major hospitals in Bogota, Medellin, and Cartagena to see their EDs and understand their work flow, systems, etc. Several of these visits occurred last year and now during this trip we've continued this work. An important aspect of this process is creating lasting collaborative relationships with the residency program directors, faculty and residents. As these partnerships grow there will be space for future electives, curriculum development and various clinical and systems research.

There are currently 5 EM residency programs with between 3-8 residents each year, typically lasting 3 years. This is a growing and very active group of residents who are working to carve out a space for the new and growing specialty. Interestingly, many of the battles that were fought over the past decades in the US, and are now mostly resolved, are repeating themselves here. There are strained relationships with other specialists, including the surgeons and internists who have traditionally run the emergency departments and hospitals. Building recognition and respect for emergency medicine and getting a very conservative medical establishment to view it as an essential part of how hospitals should function takes years, a process which is only beginning in many parts of the Colombian healthcare system. There is also a huge need to establish improved infrastructure, including ED space, staff and technology, to meet the increasing patient burden. Finally, there is a need for better training, both for the current generation of EM specialists but mostly for the thousands of general practitioners that actually staff the majority of the healthcare system and emergency departments in Colombia. These GPs usually have only 1 year of post graduate training and provide good general care but are ill-equipped to function effectively in a professional, modern ED. As this specialty grows in this country a lot of work will be needed to professionalize and make effective use of this huge workforce in the emergency system.

The second part of our research effort here is exploring the current state of point of care ultrasound within these residencies with an eventual goal of trying to support the use of this very important tool in EM practice in Colombia. We are using an ultrasound needs assessment survey which was developed 2 years ago by Trish Henwood (another HAEMR resident) for her work in Rwanda. Last year Trish and others surveyed most of the EM residents in Bogota; now we're extending our sampling pool to include the residents in the two programs in Medellin. The survey is approx 2 pages long, in spanish, and relatively quick to complete. It gives us valuable insight into how EM residents use ultrasound in their clinical work currently, what they'd like in terms of ultrasound education, and what they perceive as barriers to the growth of ultrasound in their specialty. Of the 5 EM residencies most do not have an active ultrasound curriculum but rather use ultrasound haphazardly at the several hospitals where machines are available. Almost all of the residents would like more access and training in ultrasonography and feel that it would be important to their clinical practice. Despite this however they identified barriers such as difficult political relationships with radiologists and lack of trained teachers. The difficulty with radiologist will be especially difficulty to overcome as there are clear financial incentives to maintain the status quo; radiologist are paid well to perform ultrasounds and have little desire to give up any ground to the new specialty of emergency medicine. In fact, there is a national law in place which restricts EM use of ultrasound without specific credentials. This pressure from the entrenched and powerful interests often results in pressure from hospital administrations toward EM docs wishing to use ultrasound in their care or integrate it more deeply into training programs. To overcome these pressures EM will need to keep growing in influence and begin to advocate for its position more forcefully in their hospitals, universities and eventually nationally.

As I wrap up my time here in Colombia and continue to process the things I've seen and learned, analyze our data and now begin to write up our findings I'm again thankful for the support from the GME travel grant to be able to come down here during a busy time of residency. Its been a fantastic experience filled with deepening relationships with Colombian colleagues. I'll definitely be back in the future and am excited to watch our emerging specialty continue to grow in this country.