LETTERS/REPLIES
International Engagement by United States Academic Neurology Departments: A National Survey 1
2
Michael P. H. Stanley, AB, Joseph Berger, MD, Shri Misra, MD,3 Ildefonso Rodriguez, MD,4 Victoria Elliott, MBA,5 Robert H. Brown Jr, DPhil, MD,6 and Farrah J. Mateen, MD, PhD7,8 In the recent article by Gretchen Birbeck, entitled “Careers in Global Neurology,”1 the engagement of US neurology departments was articulated. We propose that professional societies are uniquely positioned to address global neurology issues because of their range of members across geographic regions and training levels, public presence and reputation, and recognized organizational and leadership capacity. A central mission of the American Neurological Association (ANA) is to foster leadership, mentorship, and career development, including junior neurologists and neurologists-in-training. Based on this interest, and the desire to expand global efforts of the ANA, a survey was sent by the ANA International Outreach Team to all US academic neurology department chairs. The survey was developed from an existing survey instrument of US and Canadian neurology program directors2 and distributed by email to all US academic neurology chairs by the ANA in May to July 2014. Surveys were emailed once with a reminder 4 weeks later. Chairs were asked about global health activities in their departments and could select a proxy respondent if they chose. There were 23 respondents (response rate 5 39%). Most respondents were departmental chairs (n 5 13) or vicechairs (n 5 4). Respondents were from the Northeast (n 5 6), Midwest (n 5 5), Southeast/Southwest (n 5 11), and Northwest (n 5 1). More than 80% of respondents (n 5 19) noted the presence of a formal office or center for global health in their institution, whereas slightly less than half (n 5 11, 48%) reported established collaborations or formal partnerships with universities/academic institutions in lower- and middle-income countries (LMICs; Table 1). Interest in global health activities among both faculty and medical students was reportedly 82%, whereas 60% of respondents reported their department currently participates in some form of global health activity. When respondents were invited to respond to a number of suggestions on how to advance global health projects within neurology, funding for travel for both high-income country and LMIC physicians was considered most valuable. This survey quantifies the assertions by Dr Birbeck and others that academic neurologists and neurology trainees have a high level of interest in global health, and that there are several pragmatic impediments to implementing sustainable global health programs.3 First, funding is difficult to obtain; major funders of US academic medical research gen-
C 2015 American Neurological Association 150 V
TABLE 1. Global Activities of US Academic Neurology Departments, n 5 23
Responses of Department Representative
No.
%
Interest in global health from faculty or medical students Yes
19
82
No
2
9
Uncertain
2
9
Yes
14
61
No
8
35
Uncertain
1
4
Participation in global health activities
Activities currently pursued in a foreign country Clinical teaching
11
48
Clinical services
9
39
Clinical or epidemiological research
7
30
Basic science/translational/ genetics research
3
13
Telemedicine
2
9
Presence of formal partnerships/established collaborations with universities/academic institutes in LMIC Yes
11
48
No
10
43
Uncertain
2
9
Presence of formal office or center for global health Yes
19
82
No
2
9
Uncertain
2
9
Yes
16
70
No
5
21
Uncertain
2
9
1
3
19
2
5
31
Faculty participation in LMIC
No. faculty participating
Letters/Replies
TABLE 1: Continued
Responses of Department Representative
No.
%
3
4
25
4
1
6
5
3
19
Yes
4
17
No
9
40
Uncertain
10
43
Faculty participation in humanitarian relief beyond regular duties
Formal funding mechanisms for global health efforts (responding positively) Directly through the department
6
55
Donations through industry or pharma
0
0
Individual research grants
3
27
Philanthropy through private donors
0
0
NIH-funded training programs
2
18
Positive responses to possible global health initiatives by the ANA Travel funding for US faculty or trainees to go to a low-income country
19
83
Formal partnerships with specific universities and/or neurology departments in low-income countries
17
74
Travel funding for faculty from a developing country to visit or train in your department
17
74
Travel funding for faculty from a developing country to attend the ANA annual meeting
16
70
Formal partnerships with NGOs with established programs in low-income countries
15
65
Online curricula for neurologists hoping to volunteer in a low-income country
13
57
Online grand rounds on the Internet, given by experts from various locations worldwide
8
35
Potential Conflicts of Interest
ANA 5 American Neurological Association; LMIC 5 lower- or middle-income country; NGO 5 nongovernmental agency. July 2015
erally did not contribute to the current global health endeavors in academic neurology departments. As a consequence, neurology departments themselves were most likely to fund international endeavors. In the absence of sustained funding, it is difficult to establish long-term programs. Second, only about half of the respondents in global health activities had a formal partnership with an institution in an LMIC. Long-term relationships are critical to mutual benefit between high-income country and LMIC investigators and should be considered the goal of such endeavors. Beyond diversified funding for global health initiatives, faculty-level engagement is likely to be most effective in providing the critical link between trainees’ interests and a meaningful and responsible experience for the various international stakeholders. Organizations such as the ANA are well positioned to address these variations and determine how collective efforts can be improved. There are several limitations to this survey. Only 39% of institutions that received a survey responded, yielding a sample size of 23 respondents. It is possible this group is too small to make inferences to all US neurology departments. Our targeted respondents reflect the most up-to-date list of department chairs in neurology known to the ANA; however, other lists may contain departmental chairs who are not currently ANA members. There is a risk of survey response bias; chairs from institutions that do not participate in global efforts may have chosen not to respond. This would overestimate the number of institutions that are engaged and interested in global health. Also, in some cases, the respondents may not accurately reflect the global health interests and activities of their institutions. In summary, neurology departments based in US academic institutions are increasingly confronted with the question of how neurology overseas, particularly in LMICs, can be incorporated into their academic missions. We hope this national survey provides some foundational steps to understand how best to “go global” despite the limited infrastructure and human resources that presently exist for neurological care in LMICs.
J.B.: grants, PML Consortium, Biogen Idec, Novartis; data monitoring–PML Adjudication Board, Amgen, AstraZeneca, BristolMyers Squibb, Eisai, Janssen, Millennium, Parexel, Pfizer, Roche, Takeda; consultancy, Genentech, Genzyme, Incyte, Inhibikase, Johnson and Johnson, Novartis; lecturer, American Academy of Neurology; cochair, Consortium of MS Centers. 1
Tufts University, Boston, MA University of Pennsylvania, Philadelphia, PA 3 University of California, Los Angeles, Los Angeles, CA 4 Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico 5 American Neurological Association 6 University of Massachusetts Medical School, Worcester, MA 7 Massachusetts General Hospital, Boston, MA 8 Harvard Medical School, Boston, MA 2
151
ANNALS
of Neurology
References 1.
Birbeck GL. Careers in global neurology. Ann Neurol 2014;75:805–809.
2.
Lyons JL, Coleman M, Engstrom JW, Mateen FJ. International electives in neurology training: a survey of U.S. and Canadian program directors. Neurology 2014;82:119–125.
3.
Fleisher JE, Mateen FJ. Neurology goes global: international volunteer opportunities. Neurol Clin Pract 2014;4:239–246.
DOI: 10.1002/ana.24366
might be persuaded to support such endeavors, and professional societies would likely be better suited than individuals to explore such possibilities.
Potential Conflicts of Interest Nothing to report.
Departments of Neurology and Public Health, University of Rochester, Rochester, NY
Reply
DOI: 10.1002/ana.24359
Gretchen L. Birbeck, MD, MPH, DTMH Drs Stanley et al are thanked for their informative response. The results of their survey of US academic neurology departments provide important quantitative estimates of the interests and engagement these departments have in the global neurology arena. Certainly professional societies from regions with more abundant neurologic expertise are well positioned to provide the leadership and infrastructure needed to focus and facilitate the energy their membership has in international research, education, and clinical activities. Formal collaborations between groups such as the American Neurological Association and professional societies in low and middle-income countries might be particularly fruitful (eg, Society of Neuroscientists in Africa). I also wholeheartedly agree that sustainable funding streams are needed to foster the development of long-term partnerships. Programs (and globally focused faculty) that rely solely on the good will and coffers of department chairs are vulnerable to personnel changes as well as relatively modest fluctuations in a department’s discretionary spending capacity. Research collaborations can be supported through traditional mechanisms such as the US National Institutes of Health, but creative approaches are needed to identify funding options for the clinical and educational aspects of global neurology. Given the scope and burden of neurologic disorders, international development agencies (eg, United States Agency for International Development)
Nonsynonymous Variants in MC1R Are Rare in Chinese Parkinson Disease Cases Jia Nee Foo, PhD,1 Yi Zhao, MD, PhD,2 Jianjun Liu, PhD,1 and Eng-King Tan, MD2,3 Tell-Marti et al reported an association of the nonsynonymous variant p.R160W (rs1805008) in the melanocortin 1 receptor (MC1R) gene with Parkinson disease (PD) in the Spanish population.1 This variant is common, present in 1–7% of European populations and associated with an approximate 2-fold (odds ratio 5 2.10) increased risk for PD. Their findings suggest that common nonsynonymous variants in MC1R may comodulate both PD and melanoma risk and may partially explain epidemiological observations of the co-occurrence of melanoma and PD.2 Melanoma occurs at a much lower incidence in Asians compared to Europeans, and the sun exposure risk differs between the regions.3,4 Here, we aim to investigate whether nonsynonymous variants in MC1R influence risk of PD in the Chinese population. We first genotyped rs1805008 in 778 PD cases (age 5 68.0 6 10.0 years, age at PD onset 5 63.6 6 10.5 years, 57.3% males) and 517 healthy controls (age 52.0 6 11.5 years, 57.3% males) of Chinese ethnicity from Singapore. This p.R160W variant was not found in any of our case or control
TABLE. Association of MC1R Nonsynonymous Variants in 778 Parkinson Disease Cases and 571 Controls of Chinese Ethnicity from Singapore
SNP
Amino Acid Change
Reference/ Alternate Allele
Frequency, Cases
Frequency, Controls
Fisher Exact p
OR (95% CI)
rs34090186
p.R67Q
A/G
0.96%
1.35%
0.446
0.709 (0.341–1.475)
rs2228479
p.V92M
A/G
32.01%
29.98%
0.279
1.099 (0.927–1.304)
rs33932559
p.I120T
C/T
3.47%
3.77%
0.747
0.917 (0.603–1.395)
rs1805007
p.R151C
T/C
0.00%
0.00%
1.000
NA
rs1805008
p.R160W
T/C
0.00%
0.00%
1.000
NA
rs885479
p.R163Q
G/A
61.12%
61.61%
0.805
0.979 (0.833–1.151)
CI 5 confidence interval; NA 5 not applicable; OR 5 odds ratio; SNP 5 single nucleotide polymorphism.
152
Volume 78, No. 1
International Engagement by United States Academic Neurology Departments: A National Survey 1
2
Michael P. H. Stanley, AB, Joseph Berger, MD, Shri Misra, MD,3 Ildefonso Rodriguez, MD,4 Victoria Elliott, MBA,5 Robert H. Brown Jr, DPhil, MD,6 and Farrah J. Mateen, MD, PhD7,8 In the recent article by Gretchen Birbeck, entitled “Careers in Global Neurology,”1 the engagement of US neurology departments was articulated. We propose that professional societies are uniquely positioned to address global neurology issues because of their range of members across geographic regions and training levels, public presence and reputation, and recognized organizational and leadership capacity. A central mission of the American Neurological Association (ANA) is to foster leadership, mentorship, and career development, including junior neurologists and neurologists-in-training. Based on this interest, and the desire to expand global efforts of the ANA, a survey was sent by the ANA International Outreach Team to all US academic neurology department chairs. The survey was developed from an existing survey instrument of US and Canadian neurology program directors2 and distributed by email to all US academic neurology chairs by the ANA in May to July 2014. Surveys were emailed once with a reminder 4 weeks later. Chairs were asked about global health activities in their departments and could select a proxy respondent if they chose. There were 23 respondents (response rate 5 39%). Most respondents were departmental chairs (n 5 13) or vicechairs (n 5 4). Respondents were from the Northeast (n 5 6), Midwest (n 5 5), Southeast/Southwest (n 5 11), and Northwest (n 5 1). More than 80% of respondents (n 5 19) noted the presence of a formal office or center for global health in their institution, whereas slightly less than half (n 5 11, 48%) reported established collaborations or formal partnerships with universities/academic institutions in lower- and middle-income countries (LMICs; Table 1). Interest in global health activities among both faculty and medical students was reportedly 82%, whereas 60% of respondents reported their department currently participates in some form of global health activity. When respondents were invited to respond to a number of suggestions on how to advance global health projects within neurology, funding for travel for both high-income country and LMIC physicians was considered most valuable. This survey quantifies the assertions by Dr Birbeck and others that academic neurologists and neurology trainees have a high level of interest in global health, and that there are several pragmatic impediments to implementing sustainable global health programs.3 First, funding is difficult to obtain; major funders of US academic medical research gen-
C 2015 American Neurological Association 150 V
TABLE 1. Global Activities of US Academic Neurology Departments, n 5 23
Responses of Department Representative
No.
%
Interest in global health from faculty or medical students Yes
19
82
No
2
9
Uncertain
2
9
Yes
14
61
No
8
35
Uncertain
1
4
Participation in global health activities
Activities currently pursued in a foreign country Clinical teaching
11
48
Clinical services
9
39
Clinical or epidemiological research
7
30
Basic science/translational/ genetics research
3
13
Telemedicine
2
9
Presence of formal partnerships/established collaborations with universities/academic institutes in LMIC Yes
11
48
No
10
43
Uncertain
2
9
Presence of formal office or center for global health Yes
19
82
No
2
9
Uncertain
2
9
Yes
16
70
No
5
21
Uncertain
2
9
1
3
19
2
5
31
Faculty participation in LMIC
No. faculty participating
Letters/Replies
TABLE 1: Continued
Responses of Department Representative
No.
%
3
4
25
4
1
6
5
3
19
Yes
4
17
No
9
40
Uncertain
10
43
Faculty participation in humanitarian relief beyond regular duties
Formal funding mechanisms for global health efforts (responding positively) Directly through the department
6
55
Donations through industry or pharma
0
0
Individual research grants
3
27
Philanthropy through private donors
0
0
NIH-funded training programs
2
18
Positive responses to possible global health initiatives by the ANA Travel funding for US faculty or trainees to go to a low-income country
19
83
Formal partnerships with specific universities and/or neurology departments in low-income countries
17
74
Travel funding for faculty from a developing country to visit or train in your department
17
74
Travel funding for faculty from a developing country to attend the ANA annual meeting
16
70
Formal partnerships with NGOs with established programs in low-income countries
15
65
Online curricula for neurologists hoping to volunteer in a low-income country
13
57
Online grand rounds on the Internet, given by experts from various locations worldwide
8
35
Potential Conflicts of Interest
ANA 5 American Neurological Association; LMIC 5 lower- or middle-income country; NGO 5 nongovernmental agency. July 2015
erally did not contribute to the current global health endeavors in academic neurology departments. As a consequence, neurology departments themselves were most likely to fund international endeavors. In the absence of sustained funding, it is difficult to establish long-term programs. Second, only about half of the respondents in global health activities had a formal partnership with an institution in an LMIC. Long-term relationships are critical to mutual benefit between high-income country and LMIC investigators and should be considered the goal of such endeavors. Beyond diversified funding for global health initiatives, faculty-level engagement is likely to be most effective in providing the critical link between trainees’ interests and a meaningful and responsible experience for the various international stakeholders. Organizations such as the ANA are well positioned to address these variations and determine how collective efforts can be improved. There are several limitations to this survey. Only 39% of institutions that received a survey responded, yielding a sample size of 23 respondents. It is possible this group is too small to make inferences to all US neurology departments. Our targeted respondents reflect the most up-to-date list of department chairs in neurology known to the ANA; however, other lists may contain departmental chairs who are not currently ANA members. There is a risk of survey response bias; chairs from institutions that do not participate in global efforts may have chosen not to respond. This would overestimate the number of institutions that are engaged and interested in global health. Also, in some cases, the respondents may not accurately reflect the global health interests and activities of their institutions. In summary, neurology departments based in US academic institutions are increasingly confronted with the question of how neurology overseas, particularly in LMICs, can be incorporated into their academic missions. We hope this national survey provides some foundational steps to understand how best to “go global” despite the limited infrastructure and human resources that presently exist for neurological care in LMICs.
J.B.: grants, PML Consortium, Biogen Idec, Novartis; data monitoring–PML Adjudication Board, Amgen, AstraZeneca, BristolMyers Squibb, Eisai, Janssen, Millennium, Parexel, Pfizer, Roche, Takeda; consultancy, Genentech, Genzyme, Incyte, Inhibikase, Johnson and Johnson, Novartis; lecturer, American Academy of Neurology; cochair, Consortium of MS Centers. 1
Tufts University, Boston, MA University of Pennsylvania, Philadelphia, PA 3 University of California, Los Angeles, Los Angeles, CA 4 Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico 5 American Neurological Association 6 University of Massachusetts Medical School, Worcester, MA 7 Massachusetts General Hospital, Boston, MA 8 Harvard Medical School, Boston, MA 2
151
ANNALS
of Neurology
References 1.
Birbeck GL. Careers in global neurology. Ann Neurol 2014;75:805–809.
2.
Lyons JL, Coleman M, Engstrom JW, Mateen FJ. International electives in neurology training: a survey of U.S. and Canadian program directors. Neurology 2014;82:119–125.
3.
Fleisher JE, Mateen FJ. Neurology goes global: international volunteer opportunities. Neurol Clin Pract 2014;4:239–246.
DOI: 10.1002/ana.24366
might be persuaded to support such endeavors, and professional societies would likely be better suited than individuals to explore such possibilities.
Potential Conflicts of Interest Nothing to report.
Departments of Neurology and Public Health, University of Rochester, Rochester, NY
Reply
DOI: 10.1002/ana.24359
Gretchen L. Birbeck, MD, MPH, DTMH Drs Stanley et al are thanked for their informative response. The results of their survey of US academic neurology departments provide important quantitative estimates of the interests and engagement these departments have in the global neurology arena. Certainly professional societies from regions with more abundant neurologic expertise are well positioned to provide the leadership and infrastructure needed to focus and facilitate the energy their membership has in international research, education, and clinical activities. Formal collaborations between groups such as the American Neurological Association and professional societies in low and middle-income countries might be particularly fruitful (eg, Society of Neuroscientists in Africa). I also wholeheartedly agree that sustainable funding streams are needed to foster the development of long-term partnerships. Programs (and globally focused faculty) that rely solely on the good will and coffers of department chairs are vulnerable to personnel changes as well as relatively modest fluctuations in a department’s discretionary spending capacity. Research collaborations can be supported through traditional mechanisms such as the US National Institutes of Health, but creative approaches are needed to identify funding options for the clinical and educational aspects of global neurology. Given the scope and burden of neurologic disorders, international development agencies (eg, United States Agency for International Development)
Nonsynonymous Variants in MC1R Are Rare in Chinese Parkinson Disease Cases Jia Nee Foo, PhD,1 Yi Zhao, MD, PhD,2 Jianjun Liu, PhD,1 and Eng-King Tan, MD2,3 Tell-Marti et al reported an association of the nonsynonymous variant p.R160W (rs1805008) in the melanocortin 1 receptor (MC1R) gene with Parkinson disease (PD) in the Spanish population.1 This variant is common, present in 1–7% of European populations and associated with an approximate 2-fold (odds ratio 5 2.10) increased risk for PD. Their findings suggest that common nonsynonymous variants in MC1R may comodulate both PD and melanoma risk and may partially explain epidemiological observations of the co-occurrence of melanoma and PD.2 Melanoma occurs at a much lower incidence in Asians compared to Europeans, and the sun exposure risk differs between the regions.3,4 Here, we aim to investigate whether nonsynonymous variants in MC1R influence risk of PD in the Chinese population. We first genotyped rs1805008 in 778 PD cases (age 5 68.0 6 10.0 years, age at PD onset 5 63.6 6 10.5 years, 57.3% males) and 517 healthy controls (age 52.0 6 11.5 years, 57.3% males) of Chinese ethnicity from Singapore. This p.R160W variant was not found in any of our case or control
TABLE. Association of MC1R Nonsynonymous Variants in 778 Parkinson Disease Cases and 571 Controls of Chinese Ethnicity from Singapore
SNP
Amino Acid Change
Reference/ Alternate Allele
Frequency, Cases
Frequency, Controls
Fisher Exact p
OR (95% CI)
rs34090186
p.R67Q
A/G
0.96%
1.35%
0.446
0.709 (0.341–1.475)
rs2228479
p.V92M
A/G
32.01%
29.98%
0.279
1.099 (0.927–1.304)
rs33932559
p.I120T
C/T
3.47%
3.77%
0.747
0.917 (0.603–1.395)
rs1805007
p.R151C
T/C
0.00%
0.00%
1.000
NA
rs1805008
p.R160W
T/C
0.00%
0.00%
1.000
NA
rs885479
p.R163Q
G/A
61.12%
61.61%
0.805
0.979 (0.833–1.151)
CI 5 confidence interval; NA 5 not applicable; OR 5 odds ratio; SNP 5 single nucleotide polymorphism.
152
Volume 78, No. 1
