Report from Dr Meri Grigoryan, from Yerevan, Armenia visiting the Department of Neurology, Universitatsklinikum Heidelberg, Germany under the supervision of prof. Peter Ringleb
First of all I would like to express my gratitude to the whole EAN team for giving me such a brilliant opportunity to observe and work 1,5 month with the highly specialized vascular neurology team in University Clinic of Heidelberg under the supervision of prof. Peter Ringleb and Prof. Simon Nagel. The clinic was very well organised structure led by Prof. Dr. med. Wolfgang Wick and was divided into 5 Units.
Neuro 1 – Neurooncology Unit
Neuro 2 – Normal Unit
Neuro 3 – Private Health insurance
Neuro 4 –Neuro Intensive Care Unit
Neuro 5 – Stroke Unit
Most of my practice I spent in the Stroke Unit. My day started at 8:00 am, the doctors were gathering in the Stroke Unit and discussing the patients. Every day at 8:30 and 13:00 there was half hour radiology conference, where radiological images of the patients from all over the clinic were discussed. This helped me broaden my knowledge of imaging results interpritation. After that, we were going on ward rounds and seeing patients with different vascular problems and discussing the diagnoses and treatments. Acute stroke patients were arriving during the day to the department from the ER. In the Stroke Unit there was a multidisciplinary team approach between neurologists, neuroradiologists, nurses, physiotherapists, speech and language therapists, psychologists, ergotherapists and social therapists. I had an opportunity to compare the clinic I work and the clinic that was hospitating me. The health system in Germany is very different from my home country, where the patients pay for their treatment themselves. The public insurance in Germany allows to do all the modern expensive treatments and procedures for the patients. Every Thursday 7:45 am we had journal clubs, which were beneficial to enrich my knowledge.
I have been in the Emergency Department for few days, where I saw patients with acute ischemic strokes. I got acquainted with the indications and contraindications of thrombolysis and observed the process of applications of r-TPA and endovascular surgery.
For hemispheric strokes with severe edema and elevated intracranial pressure decompressive craniectomies was often used. I was also very excited to see the Neuroradiology Department, where I saw procedures, which are not held in my country such as: trombectomies, aneurysm coilings, AVM embolisations, carotid angioplasties and stentings. The interventional radiologist gave me much information and explanations about the procedures.
My free time I was spending in MRI and CT rooms. The clinic has 3 MRIs (3T) and 1 CT. The devices were provided with the latest diagnostic programs for early ischemic changes in the brain. Neuroradiologists have wide knowledge of CT and MRI imaging interpritation.
I had also an opportunity to meet outpatients with prof. Ringleb, teaching me a lot about intracranial doppler, precerebral artery ultrasonography and for the clinical practice. I also visited the Neuro Intensive Care Unit, which was provided with all the necessary medications and devices. I also found some time to enjoy the beauty of the nature and old buildings in Heidelberg.
Beeing in Germany for 6 weeks I learned a lot in German language, which motivates me to start language courses when I go back to my country. My collegues were quite helpful when I had difficulties with understanding German language and whenever I had questions. During my 6 weeks practice I learned more about stroke treatment, imaging and different ways to dignostics. I have learnet new treatment strategies and drug approaches that are not used in Armenia. I improved my knowledge in vascular neurology.
I would like to thank the Head of the Cerebrovascular Neurology Department Prof. Dr. med. Peter Ringleb and the consultant of stroke Unit Prof. Dr. Simon Nagel for their support and kind attitude to me. They were neurologists with great experience.
Again special thanks to EAN for helping me to widen my knowledge in this field of neurology. The experience which I gained in Heidelberg during 6 weeks practice is invaluable and will be helpful for my further professional activity. I will share my gained knowledge with my collegues and definitely recommend all young neurologists to participate in this programme.
Report from Dr Andrejs Kostiks, from Riga, Latvia visiting the Department of Neurology, Atkinson Morley Wing, St George’s Hospital, London, UK under the supervision of Dr Jeremy Isaacs
I would like to thank EAN for giving me such great opportunity to visit the St George’s University Hospital, NHS Foundation Trust, Blackshaw Road, Tooting, London, and gain my knowledge and experience in cognitive neurology.
I spent 6 weeks from 19.04.2017 until 01.06.2017 at the Department of Neurology in St George’s University Hospital. During the fellowship, I observed several clinics that where associated with cognitive disorders. Primary I have visited Dr Jeremy Isaacs, who was my supervisor during my fellowship and I have observed first time dementia clinics and dementia follow up clinics. Since St George’s university hospital is not the primary memory service in London I was able to observe more complicated cases of mild cognitive impairment and dementia, where diagnosis of a specific type of dementia is not that straight forward.
Dr Isaacs has taught me how to approach a dementia suffering patient and what clinical features of a specific type of dementias are. Since the diagnosis of dementia is quite complicated in patient with high cognitive reserve, which is where neuropsychological evaluation is very helpful to identify flaws in cognitive domains. I also had an opportunity to observe Prof. Peter Garrard and Dr. Kuwan Moodley clinics which also were attributed with diagnosing patients with dementia and cognitive impairment. Prof. Peter Garrard had taught me to pay attention on fluency of language in patient complaining about cognitive impairment and impotency to ask the patient and his relatives about behavioral changes that could have happened during the progression of the disease.
I had an opportunity to meet and observe Dr Kiran Hans-Tangri neuropsychological clinic. It was very interesting to see what tests are performed to test cognitive impairment. One patient assessment is 3 hours long during and during the assessment the patient is given several similar test to fully access patient’s cognitive domains and observe the performance. One of the main problems is associated with language assessment because there are not so many tests that are in different languages to properly assess patient in his native tongue.
Another clinic that I have visited was movement disorders clinic with Dr. Dominic Paviour. I had the opportunity to see patient with Parkinson’s disease before deep brain stimulation and after. It is very important to valuate patient’s moments and cognition before the procedure as well as after the procedure to understand if the procedure was beneficial for the patient.
It was a very great and educational experience and I would like to thank all the doctors who were very helpful and understanding as well as EAN for this wonderful opportunity.
Report from Dr Marta Lopes, from Trofa, Portugal visiting the Epilepsy Department, The National Hospital for Neurology & Neurosurgery, Queen Square, London, UK under the supervision of Dr. Sofia Eriksson
During this fellowship, I had the opportunity of participating in several educational and clinical activities at NHNN and Institute of Neurology. Most of the clinical activities were in the Epilepsy field, but also in Sleep Disorders.
I participated in the following activities:
- Epilepsy and Sleep Outpatient clinic at Queen Square;
- Epilepsy and Neurogenetics Outpatient clinic at the Epilepsy Society, Chalfont;
- Wardrounds – Telemetry and Gowers Unit – patients undergoing diagnostic and presurgical evaluations, including video-EEG telemetry, intracranial electrode recordings, SPECT; also sleep studies;
- Weekly multidisciplinary team meetings in which surgical candidates and sleep studies are discussed
- Observation of sleep reporting;
- Weekly Gowers and Critchley rounds in which patients from all neurological spheres are presented and discussed;
- Wide range of lectures and talks arranged by the National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology including weekly clinical pathology conference;
- Participation in the Southern Sleep Forum and Queen Square GP Seminars on Sleep Disorders;
- Participation in CBT sessions for insomnia with Hugh Selsick of Royal London Hospital for Integrated Medicine, also part of UCLH Trust, and observation of insomnia clinics;
- Attended the Neuromuscular Course, “Update in Neuromuscular Disorders” 23-26 May 2017.
I consider that this fellowship was very important for my training as a future neurologist, particularly because of my interest in Sleep Disorders. I could observe several patients with sleep disorders, understand treatment strategies and improve my abilities in interpretation of sleep studies. I could also enrich my knowledge in the epilepsy field. All the educational activity in NHNN and Institute of Neurology were also very interesting and allowed me to contact with rare, uncommon and atypical neurological disorders.
Report from Dr Madona Sekhniashvili, from Tbilisi, Georgia visiting the Neuromuscular Division and Clinical Neurophysiology, Neurologische Klinik der Universität, Würzburg, Germany under the supervision of Dr. Daniel Zeller and Prof. Klaus Toyka
At the beginning of my report I would like to express my gratitude and thank to the EAN for giving me the great opportunity to perform my 6 week clinical fellowship in the University Department of Neurology and Hospital. I had wonderful 6 weeks in this traditional German University located in an amazing, attractive, old town with interesting history and many cultural monuments. The University Hospital of Würzburg is a 1500 bed hospital providing maximal care in all medical specialties for Northern Bavaria, Eastern Hesse and Northern Baden Württemberg, providing excellent care for 3 large neighboring states of the Federal Republic of Germany. At the same time it is one of the leading research centers in Germany networking with all basic science institutes at the university. Health care services in neurological field are wide and success rate of the treatment are high. Quality and introduction of technologies allow clinic to own several certificates from world-famous organizations (Cooperation for Transparency and Quality Management (CTQ))
The principal aim of my visit was to gain more experience in clinical neurophysiology, especially in the diagnosis of neuromuscular diseases because that is my focus in Georgia.In the field of Neuromuscular disorders I had the chance to see many patients with Polyneuropathies, Myopathies, Neuroimmunological diseases including the Guillain-Barre-syndrome and chronic polyneuritis, Myasthenia gravis, neuropathic pain all of whom had systematic work-up in the electrophysiology labs and in the ultrasound lab. Some had muscle or nerve biopsies with full diagnostic neuropathology in the department.
First of all I would like to thank Professor Klaus V. Toyka, the former departmet chairman and Hospital director, whose special fields are neuromuscular disorders, electrophysiology and neuroimmunological disoredres including muscle, PNS and CNS. I have been lucky to have his enormous support at any level of my fellowship – from my application process to clinical fellowship period. He and his wife made me feel at home. I appreciate Professor Toyka’s effort to share his long, very interesting experience and universal knowledge of neurology and electrophysiology. He gave me very valuable interactive teaching sessions about different topics: Indications and techniques for surface EMG, Biology and pathology of the motor unit, The basis of high-frequency discharges including myotonia, Pitfalls in testing for neuromuscular transmission disorders, Indication for extended nerve conduction studies, Diagnostic tests for follow-up examination in treatable myopathies and neuropathies. We discussed 25 neuromuscular cases from Tbilisi with electrophysiologic evaluation, which I had recorded in the EMG lab. I am thankful for the medical books he gave me from his private library, and for his time and energy spent for my professional carrier. He gave me enormous motivation to keep on studying this field.
I would not have met Professor Toyka, if there was not the EAN regional teaching course in Georgia, Kutaisi in 2016 organised by the Georgian-born Professor Zaza Katsarava, who is head of neurology departmentat the evangelical hospital in Unna and a professor of neurology at the University of Essen in Germany, and is the 1st vice president of the European Headache Federation. I am very thankful to him, as he gave me the opportunity to be involved in RTC- EMG workshop held by Prof. Toyka. There I learned from Professor Toyka about pseudo-monopolar stimulation techniques, which is more precise in locating peripheral nerves and is less painful for the patient when examining proximal nerve and facial nerve branches, most strikingly when using repetitive nerve stimulation for neuromuscular transmission disorders. At the end of the RTC I asked him to become my host when applying for the EAN fellowship.
I express my gratitude to head of neurophysiology department PD. Daniel Zeller, with whom I took part in the daily activities of the EMG laboratory. I was well received by him and his team and was integrated in all daily activities from day one to the end. I was involved in the clinical diagnoses of neuromuscular disease patients with different kind of mono- and polyneuropathies, plexopathies, radiculopathies, spinal canal stenosis, myopathies, myasthenia. In the outpatient clinic I saw all types of neuromuscular patients with a wide variety of disorders especially with rare entities, and including genetic disorders: stiff person syndrome, ALS, PROM/DM2 (first described by the late Prof. K. Ricker at this department), CIDP, idiopathic inflammatory distal polymyositis, Becker’s muscular dystrophy, oculopharyngeal muscular dystrophy, facioscapulohumeral muscular dystrophy, hereditary spastic paraplegia and others. I improved my practical skills in nerve conduction studies and in EMG. It was a new experience for me to see the technique of many other electrophysiologic tests including all types of evoked potentials: VEP, AEP, SEP, TMS, BR, QST, and SSR tremor surface EMG analysis, and also the PNS ultrasound examination. I had the opportunity to perform outpatient clinical activities with the team. Every afternoon PD. Zeller discussed all electrophysiology tests and patient cases performed in the department throughout the day, which were first interpreted by residents, than corrected by the head of unit. He allowed me to attend his consultations and showed me several Botulinum toxin injections. PD. Zeller also sent me many articles, scales and PDF files about different topics I was interested in, and I also had permission to use his and the clinical library.
I also had a first experience with diagnostic ultrasound in neuromuscular disorders, particularly in peripheral neuropathies. In addition, Professor Nurcan Üceyler gave me the opportunity to see many nerve ultrasound examination of inflammatory polyneuropathy patients. Both Prof. Üceyler and Prof. Claudia Sommer introduced me kindly to the histopathology of muscle and nerve biopsies. The department holds its independent and integrated unit of neuropathology formerly headed by Prof. Toyka and Prof. Sommer. I was invited to review biopsies of some patients in the weekly pathology conferences. I have seen diagnostic and technical aspects of specific muscle and nerve disorders learning about the cryostat cutting and embedding and staining techniques. (histochemistry,I mmunohistochemistry and histology). With Prof. Sommer’s kind support I was involved in morning rounds of the unit. I also had the privilege discussing many patient cases, several times every week. She was willing to answer all my questions extensively.
Moreover, I had the chance to participate and follow different on-going clinical studies in the Unit. I improved my theoretical knowledge with attending the weekly clinical conferences presenting unusual cases. I also could prepare seminars on two topics and gave one case presentation as well.
During my stay I had the pleasure to attend two important academic meetings: „Continuing education symposium“ and the „Annual meeting of the Bavarian Neuromuscular Centers, organized by the neuromuscular group at the University of Würzburg“, with current research project data presentation and clinical lectures.
I also was invited to attend a complicated neurosurgical operation at the basis of the skull with Intraoperative neurophysiological monitoring and would like to thank the vice-chairwoman of the Department of Neurosurgery, Professor Matthis and Ms.Allmen for sharing their experience. I received the invitation to return for formal training if needed. Beyond the clinical program I had the honor to be invited by the Toyka family on various classic music concerts and other cultural events in Würzburg with great pleasure, within the Mozart-Festival and the Hafensommer Festival, and also to their home meeting interesting and very kind people and receiving many memorable gifts.
IN CONCLUSION: I could extend my knowledge in my field of interest during the 6-week EAN fellowship. The clinical fellowship meant a great chance for me to observe numerous aspects of electrophysiology, for gaining experience of making the diagnosis and learn about management of patients with common and rare neuromuscular disorders, and to have a lot of pleasant memories. It was the best opportunity I have ever had before to learn how is performed full spectrum of neurophysiologic tests, interpreted and integrated in the clinical point of view. I am thankful to all clinical neurophysiology team (doctors, MTAs, workers) to all professor and colleagues for support, help and kindness.
Everything was an example of excellence. It was the incredible stimulating, valuable experience, new motivation and the ideas for the future. This fellowship has definitely increased my interest in pursuing a career in NMD. I can bring lots of impressions to my home country.
Once again, thank to the EAN and Professor Toyka for a wonderful six weeks. I am very thankful to Professor Marina Janelidze, M.D,Ph.D head of department of Neurology S.Khechinashvili University Hospital Tbilisi State Medical University and Professor Natela Okudjava Ph.D ,M.D. head of SEIN-SKUH epilepsy and sleep centre at the S.Khechinashvili University Hospital Tbilisi State Medical University, for giving me recommendation letters for my application. I am fortunate to be in their team.
Special thanks also go to Professor J. Volkman – director and chairman, and successor of Prof. Toyka, who supported me visiting the clinic. He and his staff were extremely welcoming and helpful.All members of the faculty at the Department of Neurology specializing in neuromuscular disorders allowed me attending the teaching program.