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I would like to begin my Clinical Fellowship Report by thanking the European Academy of Neurology for granting me an 11-week clinical fellowship at St George’s Hospital. I am exceedingly grateful to Prof. Francesca Morgante, my supervisor, an amazing doctor and person, who inspired me every day, for this great opportunity and for her support and good advice. I will not forget my colleagues from the Movement Disorders Team—Dr. Cociasu, Dr. Damas, Dr. Cucinotta, Dr. Bertaina, Dr. Gonzalez, Psych. Siciliano—for making me feel like part of the team from the beginning of my fellowship. It was a privilege to work with colleagues as kind and passionate as they are.

 During my stay, I had the opportunity to participate in:

        •          the outpatient clinic: 

DBS clinic

In this clinic I had the opportunity to see patients who already had implanted a deep brain stimulation device, for different types of disorders such as Parkinson’s disease, dystonia or tremor and who were programmed for the first time or who came to follow-ups for adjustments. I have also attended the selection of patients for DBS or other types of invasive treatment such as thalamotomy. For that, the patients had to undergo different stages of evaluation like the levodopa challenge, brain MRI and neuropsychological assessment. Once all the results were ready, each case was discussed in the multidisciplinary team meeting, which took place once a month and in which, in addition to neurologists, the neurosurgeons, DBS nurses and neuropsychologists also participated.

For a better understanding of the procedures, I had the unique opportunity to attend a thalamathomy and also to see the role of the movement disorder specialist in the operating room on how to assess the tremor and to help the neurosurgery team to find the optimal area for the lesion and to avoid the adverse effects.  

Botox clinic  

Treatment with botulinum toxin, done for patients with dystonia or tremor, was usually performed without guidance, but for the complex cases a portable EMG was used. This clinic helped me learn how to clinically assess the patients (which includes inspection and palpation of the involved muscles), where to inject different muscles, how to prepare the right dosage of botulinum toxin and what needle to use and also how to assess the outcome and manage the adverse events.

The observation of musician dystonia, the most severe movement disorder among instrumental performers which frequently terminates their professional careers, made a great impression on me. But with the use of the portable EMG, botulinum toxin and highly skilled and experienced doctor, they were able to improve and to play again.

Movement disorders clinic  

Patients with various movement disorders were consulted for diagnostic purposes or disease follow-up, including dopa-responsive dystonia, Holmes’ tremor, atypical parkinsonism (progressive supranuclear palsy, multiple system atrophy, corticobassal syndrome), Tourette’s syndrome, stimulus sensitive foot myoclonus, myoclonic dystonia, DYT1 generalised dystonia, spinocerebellar ataxia, among many others. Attending this clinic, I have enriched my knowledge and my clinical skills in the diagnosis and therapeutic approach and management of patients affected by movement disorders.

An important lesson I have learned in this clinic was the power of physical activity (like aerobic exercises, cycling, treadmill training, dancing, yoga and many others) to improve both motor and non-motor symptoms in Parkinson’s disease. Thus I will prescribe and encourage it in all my PD patients.

• the hospital day unit for complex cases that needed more attention, like the continuous subcutaneous apomorphine infusion. 
• I also attended the general neurology ward for one week. I got to see patients suffering from various neurological diseases (some of them very complex and rare such as progressive myoclonic epilepsy -Lafora body, DPPX, GAD, LGI1 encephalitis, neurosweet syndrome, malignant meningitis, vasculitic neuropathy, ADEM, etc.) and discuss diagnosis, treatment and different approaches to disease management.   

From an educational point of view, I was able to attend the teaching sessions which regularly took place in the neurology department.  

Despite the brief period of my fellowship, I have broadened my knowledge about the diagnosis, management and treatment of movement disorders and I am happy to say that I have seen disorders that I only read about and never met before.  

I am truly grateful to Professor Francesca Morgante and the EAN for this opportunity. It was an experience of a lifetime.

I really encourage all young neurologists to apply for this programme.

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Roman Gapeshin, St.Petersburg, Russia

Term of Fellowship: 19 September – 3 December 2021

Hosting department: Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy

Supervisor: Prof. Gabriele Siciliano

My name is Roman Gapeshin, I am a neurologist from Saint Petersburg. I participated in the EAN Clinical Fellowship Programme in 2021, visiting the Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, under the supervision of Prof. Gabriele Siciliano.

I stayed at the neurological department for 11 weeks in 2021 and these weeks were full of unforgettable experience.

First of all, I want to thank the European Academy of Neurology for this opportunity and for making my educational trip a reality. This educational grant is the greatest opportunity that can be received by young neurologists in Europe.

My week was scheduled into several themes: myopathies, motor neuron diseases, multiple sclerosis and peripheral nerve disorders. Every day I spent with my colleagues and patients who had come to the hospital.

On Monday I participated in myopathies outpatients visits. I saw many nosologies such as limb-girdle muscular dystrophy, dystrophinopathies, myotonic disorders, steroid myopathies, etc. There were also many patients referred to the neurology department from rheumatology departments and general medicine departments.

On Tuesday I visited multiple sclerosis patients. On these days we assessed patients with different stages of multiple sclerosis, different courses of the disease and, of course, different treatment options.

Wednesday was the day of motor neuron diseases. I saw many patients with confirmed diagnosis of ALS, including different variants of it, different velocity of progression, and patients with suspicion of ALS which needed expert conclusion about their state.

On Thursday, I was present during the examination of patients with peripheral nerve disorders. On this day there was a mix of patients with different pathologies, such as chronic inflammatory demyelinating polyneuropathy, Charcot-Marie-Tooth disease, hereditary neuropathy associated with pressure palsies and others. This was very interesting, how doctors decide what treatment will be the most appropriate: IVIG, hormones, or just physiotherapy, for example.

Friday was the day of primary visits of patients with suspected motor neuron diseases and ALS. Every patient took about two hours of full neurological examination, fulfilling medical documentation and of course collecting anamnesis morbi and vitae.

At the end of every day, I was with colleagues where we were discussing patients who came that day in English to clarify for me aspects which I did not understand during the appointments.

I experienced how my Italian colleagues assess neurological status in patients with neuromuscular disorders. I received many new skills regarding how to improve patient examination in my practice.

During these outpatient visits I also saw how my colleagues solve sudden worsening of patients’ conditions. One day a patient almost fell unconscious during examination. Blood pressure was 180/95 mm hg. Emergency was called immediately and the patient was admitted to the inpatient department to have appropriate diagnostics and treatment.

I was also shown a European platform CPMS for ERN networks, which helps to communicate different specialists in neuromuscular disorders even in other parts of Europe. You need to have the patient’s consent, medical history and of course clear question (or questions) to your colleagues in Europe to receive their thoughts and suggestions about your clinical case.

Finally, I want to thank Professor Gabriele Siciliano for supporting my application for the EAN grant, for support in organisation of my arrival in Pisa, which was not so easy due to coronavirus restrictions, and for organisation of my education here in Pisa. I also want to express my appreciation to the doctors at the University of Pisa, who helped me and answered all my questions which I had during my fellowship: Giulia Ricci, Francesca Bianci, Francesca Torri, Elena Merico, Divina Viola, Erica Schirinzi, Gabriele Vadi.

Thank you, University of Pisa and all people who helped me to earn an unforgettable and priceless experience!