First experience of telemedicine on epilepsy and involuntary movement disorders in Asia Hiroshi Shigeto, Taira Uehara, Hiroo Yamaguchi, Jun-ichi Kira Departments of Neurology, Neurological Institute, Faculty of Medical Sciences, Kyushu University

Shozo Tobimatsu Departments of Clinical Neurophysiology

May 21 ～ 24, 2014

Fukuoka international congress center Sun palace hotel

The number of participants 6843 Overseas participants 181

The number of international session 13 Session 9 Telemedicine, Epilepsy Session 10 Telemedicine, IVM disorders

Meeting as preparation of telemedicine in congress Sep. 18, 2013 Department of Neurology, Kyushu University hospital Telemedicine development center of Asia (TEMDEC) Nihon Koden (Electroencephalography: EEG)

Target diseases

Epilepsy, Involuntary movement disorder (IVM)

Contents of conference

Question, discussion and suggestion for patients with difficult movement symptoms

Sharing information

Patients information, neuroimaging, movie, EEG

Device for connection

Digital Video Transport System (DVTS, 30Mbps), Vidyo, Telephone

Venue and time table for telemedicine in congress

Fukuoka international congress center, May 23, 2014, afternoon

Pick up institutions in Asia Maximum four places

Scheduling of rehearsal and test connection

Schedule for the first telemedicine in neurological diseases Sep. 2013

Meeting Department of Neurology, Kyushu University hospital Telemedicine development center of Asia (TEMDEC) Nihon Koden (EEG)

Oct. 2013

Select the Connectable Institutions Pick up neurologists who may have an interest in telemedicine in Asia Check the connective device in each institute

Jan. 2014

Rehearsal 1 (APAN)

Apr. 2014

Rehearsal 2

May 2014

Telemedicine in annual meeting of the Japan Society of Neurology

Proposed institution in the field of Epilepsy and IVM Korea

Yonsei University College of Medicine, Severance Hospital Samsung Medical Center, Sungkyunkwan University Seoul National University Hospital Kang-Dong, Hallym University College of Medicine Chungnam national University Hospital

China

Beijing University Xuanwu Hospital, Capital Medical University Peking Union Medical College Neuroscience Inst. Guangzhou Medical College

Thailand

Phramongkutklao Hospital Chulalongkorn University Hospital

Indonesia

University of Indonesia

Philippines

University of the Philippines-College of Medicine Philippine General Hospital

Malaysia

University of Malaya

Taiwan

Chang Gung Medical school and hospital National Yang-Ming University National Taiwan University Hospital

India

Singapore

Australia

Singapore General Hospital Singapore National University Hospital Pan Neurology, Epilepsy and Sleep Disorders Clinic

G.B.Pant Hospital

Westmead Hospital Prince of Wales Hospital Royal Perth and Fremantle Hospitals Royal Perth Hospital

Select institutions based on connection environment Ideal, Experienced connection, Possible, Impossible

Proposed institution in the field of Epilepsy and IVM Korea

Yonsei University College of Medicine, Severance Hospital Samsung Medical Center, Sungkyunkwan University Seoul National University Hospital Kang-Dong, Hallym University College of Medicine Chungnam national University Hospital

China

Beijing University Xuanwu Hospital, Capital Medical University Peking Union Medical College Neuroscience Inst. Guangzhou Medical College

Thailand

Phramongkutklao Hospital Chulalongkorn University Hospital

Indonesia

University of Indonesia

Philippines

University of the Philippines-College of Medicine Philippine General Hospital

Malaysia

University of Malaya

Taiwan

Chang Gung Medical school and hospital National Yang-Ming University National Taiwan University Hospital

India

Singapore

Australia

Singapore General Hospital Singapore National University Hospital Pan Neurology, Epilepsy and Sleep Disorders Clinic

G.B.Pant Hospital

Westmead Hospital Prince of Wales Hospital Royal Perth and Fremantle Hospitals Royal Perth Hospital

Select institutions based on connection environment Ideal, Experienced connection, Possible, Impossible

Proposed institution in the field of Epilepsy and IVM Korea

Yonsei University College of Medicine, Severance Hospital Samsung Medical Center, Sungkyunkwan University Seoul National University Hospital Kang-Dong, Hallym University College of Medicine Chungnam national University Hospital

China

Beijing University Xuanwu Hospital, Capital Medical University Peking Union Medical College Neuroscience Inst. Guangzhou Medical College

Thailand

Phramongkutklao Hospital Chulalongkorn University Hospital

Indonesia

University of Indonesia

Philippines

University of the Philippines-College of Medicine Philippine General Hospital

Malaysia

University of Malaya

Taiwan

Chang Gung Medical school and hospital National Yang-Ming University National Taiwan University Hospital

India

Singapore

Australia

Singapore General Hospital Singapore National University Hospital Pan Neurology, Epilepsy and Sleep Disorders Clinic

G.B.Pant Hospital

Westmead Hospital Prince of Wales Hospital Royal Perth and Fremantle Hospitals Royal Perth Hospital

Select institutions based on connection environment Ideal, Experienced connection, Possible, Impossible

Selected institution in the field of Epilepsy and IVM Seoul SeoulNational NationalUniversity University Hospital Hospital

No difference

Chulalongkorn ChulalongkornUniversity University Hospital Hospital

－2 hours

Kyushu University Hospital Fukuoka International Congress Center. National NationalTaiwan TaiwanUniversity University Hospital Hospital

－1 hours

Epilepsy A chronic brain disorders of various etiologies characterized by recurrent seizures due to excessive discharge of cerebral neurons (epileptic discharges) associated with a variety of clinical and laboratory manifestations. WHO, 1973 Seizure semiology Electroencephalograph

Involuntary Movement Disorders (IVM) Parkinson disease, Essential tremor, Tardive dyskinesia・・・ Involuntary movements = tremor, myoclonus, chorea, dyskinesia, dystonia Symptom of IVM Surface Electromyogram

Flow of presentation in telemedicine of epilepsy and involuntary movement

Case history

Movie Electrophysiological data Neuroimaging

Discussion

Example of case presentation Case history

Movie

16 y.o. female CC: Involuntary movement (IVM) of her left leg PI: First appeared at the age of 8. PH: No remarkable disease FH: No similar disease Neurological examination: Normal

Electrophysiological data

Discussion

Neuroimaging

Video electroencephalograph and surface electromyograph

Video electroencephalograph and surface electromyograph

Example of case presentation Case history

Movie

16 y.o. female CC: Involuntary movement (IVM) of her left leg PI: First appeared at the age of 8. PH: No remarkable disease FH: No similar disease Neurological examination: Normal

Electrophysiological data Neuroimaging

Discussion What is the origin of this movement ? Peripheral, spinal, brain stem, brain? What is the etiology ? inflammation, focal cortical dysplasia? What kind of treatment should be taken ?

Schedule for the first telemedicine in neurological diseases Sep. 2013

Meeting Department of Neurology, Kyushu University hospital Telemedicine development center of Asia (TEMDEC) Nihon Koden (EEG)

Oct. 2013

Select the Connectable Institutions Pick up neurologists who may have an interest in telemedicine in Asia Check the connective device in each institute

Jan. 2014

Rehearsal 1 (APAN)

Apr. 2014

Rehearsal 2

May 2014

Telemedicine in annual meeting of the Japan Society of Neurology

37th Asia Pacific Advanced Network (APAN) Neurosession: Examine the involuntary movements and epilepsy symptoms using teleconference system, Jan. 23, 2013

Kyushu University, Japan Dr. Tobimatsu, Dr. Shigeto Engineer Dr. Antoku, Dr. Hu, Dr. Kudo

Chaulalongkorm University , Thailand Dr. Bhidayasiri Engineer Dr. Chakaphan

Seoul National University , Korea Dr. Jeon Engineer Dr. Cho

National Taiwan University , Taiwan Dr. Su Engineer Dr. Wu, Dr. Chiang

Discovered problems Engineer in Korea needed to have three hour trip to reach the venue in Seoul All internet speed were limited by the slowest internet speed (Vidyo).

Kyushu University, Japan Dr. Tobimatsu, Dr. Shigeto Engineer Dr. Antoku, Dr. Hu, Dr. Kudo

Chaulalongkorm University , Thailand Dr. Bhidayasiri Engineer Dr. Chakaphan

Seoul National University , Korea Dr. Jeon Engineer Dr. Cho

National Taiwan University , Taiwan Dr. Su Engineer Dr. Wu, Dr. Chiang

Schedule for the first telemedicine in neurological diseases Sep. 2013

Meeting Department of Neurology, Kyushu University hospital Telemedicine development center of Asia (TEMDEC) Nihon Koden (EEG)

Oct. 2013

Select the Connectable Institutions Pick up neurologists who may have an interest in telemedicine in Asia Check the connective device in each institute

Jan. 2014

Rehearsal 1 (APAN)

Apr. 2014

Rehearsal 2

May 2014

Telemedicine in annual meeting of the Japan Society of Neurology

Rehearsal and connection test, April 14, 2014

National Taiwan Univ. Kyoto Univ. Kyushu Univ.

Dr. Kuo, Dr. Su Engineer: Dr. Chiang, Dr. Wu Dr.Ikeda, Dr. Matsumoto, Dr. Inoue Engineer: Dr. Okamoto, Dr. Kuroda Dr. Kira, Dr. Tobimatsu, Dr. Shimizu, Dr. Shigeto Engineer: Dr. Houkabe, Dr. Hu, Dr. Antoku

Schedule for the first telemedicine in neurological diseases Sep. 2013

Meeting Department of Neurology, Kyushu University hospital Telemedicine development center of Asia (TEMDEC) Nihon Koden (EEG)

Oct. 2013

Select the Connectable Institutions Pick up neurologists who may have an interest in telemedicine in Asia Check the connective device in each institute

Jan. 2014

Rehearsal 1 (APAN)

Apr. 2014

Rehearsal 2

May 2014

Telemedicine in annual meeting of the Japan Society of Neurology

Preparation on previous day for Telemedicine in congress

Chief Engineer Dr. Antoku, Dr. Hu, Dr. Houkabe (Kyushu Univ.) Engineer's name 1. Kyushu U Hospital Dr. Hu, Dr. Houkabe 2. Seoul National University Dr. Jo. Dr. Cho 3. Chaulalongkorm University Dr. Chakaphan 4. National Taiwan University Dr. Esther, Dr. Chiang

Telemedicine

in 55 th Annual meeting of the Japanese Society of Neurology Place:Room#11 Fukuoka International Congress Center 5th Floor 【501】

International Session 9, Epilepsy , May 23, 13:40～15:20

Chair: Shozo Tobimatsu (Kyushu University) Lecture (50 minutes): Prof. Hans O. Lüders: Case Western Reserve University School of Medicine, USA. Presenter: 20min including discussion 1. Professor Chung-Chin Kuo (Su Jen Jen) Department of Neurology, National Taiwan University Hospital, Taiwan 2. Taira Uehara Department of Neurology, Kyushu University, Japan

International Session 10, Involuntary movement , May 23, 15:30～17:10

Chair: Ryuji Kaji (Tokushima University) , Nobutaka Hattori (Juntendo University) Lecture (50 minutes): Prof. Ryuji Kaji, Nobutaka Hattori Presenter: 20min including discussion 1. Professor Beom Seok Jeon: Department of Neurology, Seoul National University College of Medicine Republic of KoreaTBD 2. Professor Roongroj Bhidayasiri: Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand

International session 9 Epilepsy Chair Shozo Tobimatsu lecture Hans O Luders Presenter 1 Chung-Chin Kuo Presenter 2 Taira Uehara Participant (venue) Roongroj Bhidayasiri Akio Ikeda Riki Matsumoto Naoki Akamatsu Jin Kazutaka Hiroshi Shigeto Participant (local) Beom Seok Jeon Han-Joon Kim Kwan-Hee Ehm Woong-Woo Lee Hye-Young Park Chae-Won Shin Jirada Sringean Onanong Jitkritsadakul Ming-Kai Pan

Kyushu Univ. Case Medical Center National Taiwan Univ. Kyushu Univ.

Japan USA Taiwan Japan

Chulalongkorn Unuv Thailand Kyoto Univ. Japan Kyoto Univ. Japan Int. Univ. of health and welf. Japan Tohoku Univ. Japan Kyushu Univ. Japan Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. Chulalongkorn Unuv Chulalongkorn Unuv National Taiwan Univ.

Korea Korea Korea Korea Korea Korea Thailand Thailand Taiwan

International session 10 Involuntary movement Chair Ryuji Kaji Tokushima Univ. & Lecture Nobutaka Hattori Jyuntendo Univ Pres. 1 (Venue) Ryosuke Miyamoto Tokushima Univ. Pres. 2 (Local) Beom Seok Jeon Seoul National Univ. Pres. 3-1 (Local) Onanong Jitkritsadakul Chulalongkorn Univ. Pres. 3-2 (Local) Jirada Sringean Chulalongkorn Univ. Participant (venue) Roongroj Bhidayasiri Akio Ikeda Riki Matsumoto Hiroo Yamaguchi Participant (local) Beom Seok Jeon Han-Joon Kim Kwan-Hee Ehm Woong-Woo Lee Hye-Young Park Chae-Won Shin Ming-Kai Pan

Japan Japan Japan Korea Thailand Thailand

Chulalongkorn Univ. Kyoto Univ. Kyoto Univ. Kyushu Univ.

Thailand Japan Japan Japan

Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. Seoul National Univ. National Taiwan Univ.

Korea Korea Korea Korea Korea Korea Taiwan

Impression and thanks from participants Under great help of Mr. Chiang, he and his colleagues let us understand it is actually easy to get in touch via Telemedicine. I shall tell your message to Dr. Pan and Mr. Chiang. I also appreciate Dr. Shimizu. Actually it is interesting for operate Telemedicine, and not so difficult as I imaged before. Dr. Su National, Taiwan National University The input from you and the other discussers are especially insightful and helpful. Let’s look forward to more fruitful interactions in the future. Dr. Chung-Chin Kuo, Taiwan National University Just a short note to say thank you for organizing the successful telemedicine today. Dr. Roongroj Bhidayasiri, Chulalongkorn University Thank you very much for your dedication and hard work that made the program possible. The program was very educational and enjoyable. Thank you very much for your kind words. We enjoyed and learned a lot. Dr. Beom S. Jeon, Seoul National University

Impression and lessons we learned  Discussions with skilled doctors based on video movie were very useful and educational.  Small time difference among Asian countries is suited for sharing conference.  High speed internet is necessary for analysis of patient’s fast and small motion.  Personal information on video should be protected using mosaic or covering.  Pre-existence of personal relationship is important for the initial connection.  Knowledge of the partner’s environment concerning with internet connection is required.  Success of telemedicine depends on the cooperation of skilled engineers.

Future Plan Japan Epilepsy Center Association (JEPICA) Hokkaido Univ. Tohoku Univ. Tsuchiura Kyodo Hospital Nishi-Niigata Chuo National Hospital Juntendo Univ. Tokyo Medical and Dental Univ. Tokyo Medical Univ. Hachioji Med. Cent. Tokyo Metropolitan Children’s Med. Cent. Tokyo Metropolitan Neurological Hosp. National Center of Neurology and Psych. NTT Medical Center Tokyo Nippon Medical School Musashi Kosugi

Asanogawa General Hosp. Aichi Medical Univ. Shizuoka Institute of Epilepsy & Neurol. National Hosp. Org. Utano Hospital Kinki Univ. National Hosp. Org. Nara Medical Cent. Okayama Univ. Hiroshima Univ. Shikoku Medical Cent. for Child & Adults Kyushu Univ. National Hosp. Org.Nagasaki Medical Cent. Kagoshima Univ

Asia Oceania Epilepsy Organization JES-KES symposium Asian and Oceanian Parkinson’s Disease and Movement Disorders Congress

Korea China Taiwan Thailand

Indonesia Philippines India Australia

Summary  We introduced the first experience of telemedicine in the field of epilepsy and involuntary movement disorders.  Telemedicine in these fields are useful and educational.  Personal relationship is important for the initial connection.  Success of telemedicine depends on the cooperation of skilled engineers.  We feel deep appreciating for Dr. Shimizu and TEMDEC members.

Immunological data Anti Glutamine Receptor antibody Glu Rε2-CT1 (NR2B-CT) 0.556±0.140 0.230±0.091

Glu Rδ2-CT

HC Serum DC CSF *1

Glu Rε2-NT2 (NR2B-NT2) 0.523±0.233 0.216±0.083

Serum CSF

0.447 0.432

0.640 0.627

0.627 0.614

Serum*2 CSF*2

0.275 1.095

0.374 1.376

0.356 1.407

*1; CSF of focal epilepsy without inflamation etiology *2; 3 years later

0.765±0.429 0.316±0.171