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Editors’ Note: India is rapidly changing. Within a year, the number of neurology programs in the country has increased by 64%. Sodani and Sharma discuss the challenges academic neurology in India is facing. Factor and Jankovic raise concerns about tardive dyskinesia as a serious side effect of metoclopramide, citing the results of the randomized trial of valproate vs metoclopramide vs ketorolac in acute migraine, which showed that metoclopramide was more efficacious. The authors, Friedman et al., respond. —Chafic Karam, MD, and Robert C. Griggs, MD

REFORMS IN ACADEMIC NEUROLOGY: NEEDS OF A RAPIDLY CHANGING INDIA

Ajoy K. Sodani, Madhya Pradesh, India: In his Global Perspectives article, Dr. Sharma1 cited figures different from what is known. According to the Medical Council of India (MCI), 50,078 students from 381 medical schools are studying for an MBBS degree and 169 students are attending 59 medical schools for neurology training.2 In the last 4 years, the intake at MBBS level has increased by more than 10,000, which will provide this country with more qualified doctors. This same period saw 21 institutes initiating neurology courses, increasing intake by 33 per year.2 The departure of trained personnel from their home countries is an issue faced by less resourceful nations. Our goals are not achieved because most of the doctors do not serve in small towns and many leave this country. The nation’s education system should address the local issues, which vary according to lifestyle, ethnicity, environment, culture, and society; among countries, priorities differ with regard to the best use of available resources. However, to rewrite the undergraduate curriculum to create more emphasis on neurology is a welcome suggestion so our undergraduates and postgraduates will be able to manage neurologic disorders at a community level. Author Response: Mohit Sharma, New York: The authors thank Dr. Sodani for providing the latest numbers from MCI, which have changed since the writing of the article.1 In May 2013, 36 medical schools were offering 131 DM Neurology positions,1 and as of March 2014, 59 medical schools have 169 positions. The number of neurology positions has gone up by 29%, but 1388

Neurology 83

October 7, 2014

more importantly, the number of neurology programs in the country has increased by 64%. This difference over just 1 year is encouraging. Uneven distribution of physicians—especially neurologists—has been shown.3 The only way to resolve this issue would be an overall upgrade of the health care infrastructure in India. Dr. Sodani suggested that a nation’s education system should be designed to fulfill the local needs and priorities. A sea of neurologic diseases can be found in the vast Indian population4 and many of them remain undiagnosed. More emphasis on neurology among undergraduate and postgraduate students is required. At the same time, encouraging students to pursue neurology by involving them in outpatient clinics and different procedures could be helpful.5 © 2014 American Academy of Neurology 1. 2.

3. 4.

5.

Sharma M. Reforms in academic neurology: needs of a rapidly changing India. Neurology 2014;82;366–367. Medical Council of India. Available at: http://www. mciindia.org/InformationDesk/CollegesCoursesSearch. aspx. Accessed March 6, 2014. Khadilkar SV. Neurology: the scenario in India. J Assoc Physicians India 2012;60:42–44. Das A, Botticello AL, Wylie GR, Radhakrishnan K. Neurologic disability: a hidden epidemic for India. Neurology 2012;79: 2146–2147. Gupta NB, Khadilkar SV, Bangar SS, Patil TR, Chaudhari CR. Neurology as career option among postgraduate medical students. Ann Indian Acad Neurol 2013;16:478–482.

RANDOMIZED TRIAL OF IV VALPROATE VS METOCLOPRAMIDE VS KETOROLAC FOR ACUTE MIGRAINE

Stewart A. Factor, Atlanta; Joseph Jankovic, Houston: Friedman et al.1 reported the findings from a randomized trial comparing single-dose IV metoclopramide, valproate, and ketorolac in acute migraine. We have some concerns. The study showed that metoclopramide was more efficacious. However, if adopted as a routine antimigraine treatment in emergency departments it may lead to widespread, repeated use of metoclopramide with potentially serious consequences. Metoclopramide is a major cause of tardive dyskinesia (TD).2 Whereas most cases of TD occur after chronic use, we and others have observed that shortterm use may result not only in acute transient dystonic

Reforms in academic neurology: Needs of a rapidly changing India Ajoy K. Sodani and Mohit Sharma Neurology 2014;83;1388 DOI 10.1212/WNL.0000000000000923 This information is current as of October 6, 2014 Updated Information & Services

including high resolution figures, can be found at: http://www.neurology.org/content/83/15/1388.1.full.html

References

This article cites 4 articles, 2 of which you can access for free at: http://www.neurology.org/content/83/15/1388.1.full.html##ref-list-1

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Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.

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