Clinical Fellowship Reports 2022 – Ulm, Oxford, London

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I applied for an EAN Clinical Fellowship at the Neurology Clinic of Prof. Albert Ludolph knowing its renown for peripheral and muscular pathology. Due to the fact that Prof. Ludolph mostly approaches motor neuron disorder pathology, and that little is known regarding the treatment of this disease, I wished to learn more about treatment possibilities and means of diagnosis through EMG techniques.

I started my fellowship in the EMG laboratory, working with two residents who were coordinated by a very experienced and thorough attending physician (Dr. Regina Gastl). Because my German was not very good (B1 level at that moment) I chose to start with the EMG and then in the following weeks perhaps I would also talk to patients. The two residents working in the EMG lab were very eager to teach me everything they knew about performing nerve conduction study and electromyography. They allowed me from the second day to help them actively after explaining the steps carefully. Afterwards, having the chance to improve with every passing day, I managed to help them more in my second week in the clinic and even perform certain parts of the ENMG study alone.

At the end of the investigation, they would ask for my opinion on the case and then the attending physician would come and review the examination result and present the final conclusion for each case.

At the end of the first month, I was able to perform nerve conduction studies and electromyography on my own and I learned basic communication with patients in German. I also had the opportunity to attend muscle consultations with Dr. Rosenbohm in the clinic.

During the last week Dr. Gastl began to perform nerve ultrasonography and I had the chance to learn the basics of this very new procedure in the evaluation of a patient with peripheral nervous system pathology.

Because I also expressed interest in electroencephalography, Prof. Ludolph allowed me to observe the EEG laboratory of the clinic. I had the chance to work with Dr. Becker and Dr. Wagner, who were very eager to teach me and present their EEG department. They attended mostly to patients with status epilepticus but also evaluated patients with possible drug resistant epilepsy in order to evaluate the surgical potential.

I was impressed with how well trained the neurology residents were: they had mandatory rotations for every investigation available in the field of neurology (Doppler, EEG, EMG – with SEP, VEP, MEP). In addition to that, during their radiology rotation they were expected to interpret the magnetic resonance or computer tomography examinations performed for patients who were evaluated in the ED.

The hospital was a friendly environment for its employees and for its patients from my point of view. There were separate cafeterias for patients and employees with healthy, nutritious food at low prices, large areas for a moment of relaxation or for having a conversation with a family member of a patient or for waiting. Furthermore, there were plenty of materials available for every investigation needed. The workplace was a very safe environment for the entire fellowship, because it was mandatory for every employee to have a fast COVID test twice a week and every employee who entered the hospital received a free FFP2 mask daily.

At the end of these six weeks, I could not be more grateful for this experience. I am extremely thankful to EAN for allowing me to benefit from this fellowship. It was an unbelievable opportunity for me to learn how to perform a very complex and demanding investigation on my own. I feel more confident now when returning to my own country to perform this investigation and learn more in order to build on what I have already achieved in Germany. Moreover, I was able to see various pathologies and learn how to accurately make a differential diagnosis and guide the ENMG examination accordingly. Being in a clinic that addresses peripheral nervous system and muscle pathologies offered me the chance to see a great variety of not so frequent disorders. In addition to that, I learned more about similarities and differential diagnosis of motor neuron disease and palliative options used in Germany for ALS patients.

Every attending and resident doctor I have worked with during these past six weeks has been very attentive with me, they have tried to make me feel at home and to teach me as much as possible and to share their experience. I also made friends and kept in touch with the resident doctors from EMG; they are amazing people, and I am grateful to them for helping me during this fellowship.

In the end I would like to recommend this fellowship to every young neurologist in training. I can honestly say it has changed my life, my approach towards neurology and it has broadened my perspective regarding future directions for my career.

The only disadvantage I noticed was the fact that nobody was ready to communicate in English, although the first language stated in the fellowship description was English and the second German. They clearly understood English, I was able to talk in English when I did not find my words in German, but only on very rare occasions have I found someone ready to ease my stay at first by using English to answer to my questions or to explain a more difficult notion. On the other hand, from the third week this drawback turned into an advantage because I learned more German this way and I was able to better understand the patients and even talk to them during the ENMG.

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I completed my EAN Clinical Fellowship as a visiting neurology trainee at the Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, for a period of 12 weeks under the supervision of Dr. Isabel Leite. My primary aim was to learn more about the clinical management of Neuromyelitis Optica Spectrum Disorders (NMOSD), myasthenia gravis, and autoimmune encephalitis since I had had little contact with these patients in my practice before.

I was very pleased that after the difficult times we experienced during the pandemic and the way it affected the opportunity to do fellowships in other institutions, I was finally able to achieve this.

During this three-month period, I mainly observed patients in the outpatients clinics but also had the opportunity to see inpatients with challenging clinical pictures that needed a prompt diagnosis work-up and multidisciplinary discussions and management.

Regarding the outpatients clinics, my activity focused mainly on NMOSD, myasthenia gravis, and autoimmune encephalitis.

The Nuffield Department of Clinical Neurosciences is one of the two highly specialized national centres in NMOSD in the UK. It provides expert input on diagnosis, assessment, and treatments of these rare conditions. In the NMOSD clinic, I could observe patients with aquaporin-4 antibodies NMO, anti-MOG disease, and also some cases of suspected NMOSD where no antibody was identified. I learned more about the symptoms, natural history and role of each antibody in these diseases, which was particularly helpful for MOG disease, for which there are still many aspects of disease course that are unknown. I also learned more about the immunosuppressive drugs that are given in these diseases, particularly the factors that may influence the choice of a specific drug, adverse effects that need to be carefully addressed (as skin cancer surveillance and teratogenicity), the monitoring programme for each of the drugs that are used and even when to consider stopping immunosuppression on MOG disease.

At the myasthenia gravis clinic I mainly observed patients with myasthenia gravis (either with AChR antibodies or MuSK antibodies) and some patients with Lambert-Eaton Myasthenic Syndrome. I learned about the clinical pitfalls of myasthenia and about the therapies used in this disease. It was particularly useful to know how to manage immunosuppression in these patients and to see patients in clinical trials receiving drugs that are probably going to be available soon and be very useful in myasthenia treatment, like the ones that target the complement.

I also had the opportunity to attend the autoimmune encephalitis clinic and see patients with these disorders, mainly LGI1 antibody encephalitis. I understood the importance of an antibody-driven approach, how different follow-up and steroids tapering schedules should be chosen in face of a particular antibody, being a good example of what precision medicine is and how this improves the final outcome, sometimes preventing disease relapses.

Aside from those clinics, I regularly attended the multiple sclerosis clinic and an additional clinic with the clinical trials team. In addition, I took the opportunity to attend the motor neuron disease, mitochondrial diseases, ataxia, and muscle clinics, where I could learn and see patients with rare conditions that I had never seen before and get familiarised with the required multidisciplinary approach towards diagnosis and particularly management of complex and debilitating neurological illnesses.

This clinical experience, along with the opportunity to attend various MDT meetings, where challenging clinical cases were discussed, the MS/NMOSD journal club, and weekly Grand Rounds contributed greatly to my knowledge and to the understanding of how I can improve the medical care I provide to my patients. I was amazed to experience a different organisational system, where a multidisciplinary team of doctors, nurses, physiotherapists, psychologists, and dietitians work together to improve patient care.

I feel I have come back with a refreshed point of view of how this collaborative, multifaceted approach to the patient can be so advantageous to both the patient and the healthcare team members, in all dimensions, including safety for patients and learning for the healthcare professionals.

I am very grateful for the way I was received and for the opportunity to learn and see so many patients with different disorders. I thank all the doctors, nurses, and remaining staff in the department for the detailed explanations and for making me feel comfortable to ask all my questions. I especially want to thank Dr. Leite for her thorough explanations and for the humane and empathetic relationship that she maintains with her patients.

I am also very grateful to the EAN for this excellent programme and for being awarded this fellowship.

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I had the pleasure of performing my EAN Clinical Fellowship at the Department of Clinical Neurology, National Hospital for Neurology and Neurosurgery (NHNN), UCL, Queen Square in London. I was supervised by Prof. Henry Houlden. During the six weeks of my fellowship, I participated in a number of specialised clinics, including neurogenetics, PNS, and mitochondrial clinics, and was a clinical observer at the Department of Clinical Neurophysiology. From the very first day, I got involved in the clinical activities and was integrated into the team. I had the chance to learn more on the broad range of neuromuscular, neurogenetic and other rare disorders.

The Neurogenetics Outpatient Clinics led by Prof. Houlden took place on Friday. The patients with all kinds of neurogenetic disorders, including ataxias, spastic paraplegias, neurodegeneration, neuromuscular diseases and other rare conditions, are seen and followed up there. I learned more about the symptoms, diagnostics, genetic counselling, and rehabilitation of patients affected with genetic diseases. I also acquired knowledge on the genetic data interpretation and the specificity of long-term follow-up of patients with complex diseases. It is encouraging that although for the majority of the disease there is no treatment, some preclinical trials are taking place and patients are very interested in it.

There were a number of other clinics that I took part in. In the PNS clinics patients with peripheral neuropathies of different backgrounds were seen, including inflammatory, toxic, genetic, metabolic, infective and idiopathic. For me it was interesting to acquire knowledge on the treatment and diagnostics of rare neuropathies. During my observationship in the Department of Clinical Neurophysiology I had a possibility to learn about the latest diagnostic methods in the field of EMG/NLG, including single fibre EMG and ultrasound-guided botox treatment. I also participated in the movement disorders clinics with tremor analysis.

Moreover, I was able to work on the clinically oriented project related to CIDP. I collected clinical, electrophysiological and laboratory data from the clinical acts in a systematic way, to be analysed later on and correlated with molecular data.

The fellowship provided me with clinical knowledge on the neurogenetics and neuromuscular diseases that is difficult to acquire in a non-specialised centre. I met wonderful people with a positive attitude towards teaching who successfully combine clinics with scientific activities. All the team members were very welcoming and happy to answer questions and to share their knowledge. I would especially like to thank Dr. Sara Nagy for mentoring and support and Prof. Henry Houlden for hospitality and enabling me to visit his department. Finally, I would like to thank the EAN for giving me an opportunity and selecting me for the Clinical Fellowship.