Editors’ Note: In WriteClick this week, Dr. Sethi considers the responsibility that doctors of Indian origin practicing in the United States might feel to improving medical care in their home country. Author Sharma suggests a way forward. Dr. Grant proposes that differences in vitamin D levels may contribute to racial disparities in infection and stroke mortalities. Authors Levine et al. refute the connection. —Megan Alcauskas, MD, and Robert C. Griggs, MD
Sharma M. Reforms in academic neurology: needs of a rapidly changing India. Neurology 2014;82:366–367.
REFORMS IN ACADEMIC NEUROLOGY: NEEDS OF A RAPIDLY CHANGING INDIA
ACUTE INFECTION CONTRIBUTES TO RACIAL DISPARITIES IN STROKE MORTALITY
Nitin K. Sethi, New York: Dr. Sharma1 suggests ways to reform neurology services in India to meet the needs of this vast population. Similar to other US neurologists of Indian origin, I completed medical school and internal medicine residency training in India before coming to the United States for neurology training. I soon assimilated into the American medical system yet I struggle to determine my responsibilities to the country that made me a doctor. US neurologists of Indian origin are in a unique position to address some of the disparities within neurology services in India. We have the skills, finances, and resources to help the reform in India and enhance accessibility to people in remote areas—not just the major metropolitan cities. We could also aid in improving the standards of training including subspecialty training. All we need is better organization and the drive to succeed.
William B. Grant, San Francisco: Levine et al.1 reported that acute infection contributes to racial disparities in stroke mortality. However, the odds ratios (ORs) for infections were similar for white and black participants. Differences in vitamin D status may explain the findings. Black Americans have mean serum 25-hydroxyvitmin D [25(OH)D] levels of about 16 ng/mL, compared to 26 ng/mL for white Americans.2 This difference may account for black– white disparities in a number of health outcomes. Low 25(OH)D levels are associated with increased risk for stroke in observational studies.3 Low serum 25(OH)D levels are also associated with increased risk of acute respiratory infections in observational studies.4 In urinary tract infections, higher serum 25(OH)D levels are associated with increased production of cathelicidin (LL37) in response to Escherichiacoli infection; lower serum 25(OH)D levels are more likely to result in infections and increased severity of infection. The authors reported that stroke hospitalizations related to infection occurred most often in December, followed by March, October, and November.1 These are months with lower serum 25(OH)D levels due to solar ultraviolet B irradiance as an important source of vitamin D.
Author Response: Mohit Sharma, New York: I thank Dr. Sethi for his comments. India, like other developing countries, is facing health care–related problems. There are many talented neurologists in India but the lack of infrastructural support curbs their ability to perform. This lack of support will not attract Indian physicians who trained abroad to return and practice. The solution lies in greater budgetary commitment—particularly in the public health sector. Furthermore, neurology subspecialty training needs to be set up in India, and this warrants the attention of US-based neurologists of Indian origin as well as the global academic neurology community. Close collaboration among the Indian Academy of Neurology, the American Academy of Neurology, the World
Author Response: Deborah Levine, Kenneth M. Langa, Mary A.M. Rogers, Ann Arbor, MI: We thank Dr. Grant for his interest. We found a racial difference in the strength of the association between infection and death from ischemic stroke. If this difference were due to racial variation in vitamin D levels, one may question why this would only occur prior to death but not prior to strokes that were not Neurology 83
September 2, 2014
Reforms in academic neurology: Needs of a rapidly changing india Nitin K. Sethi and Mohit Sharma Neurology 2014;83;949 DOI 10.1212/WNL.0000000000000788 This information is current as of September 1, 2014 Updated Information & Services
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