Articles – Page 24

Tour Through the WFN Continues

The Finance Committee and the Specialty Group on Neuroepidemiology

By Wolfgang Grisold

Wolfgang Grisold

In this issue of World Neurology, we would like to continue to introduce you to one committee and one specialty group. The committee/specialty group is introduced by the respective chairs, who were asked to explain their tasks and activities to our membership. Further details, such as the list of committee/specialty group members can be found on the WFN website, as well as email addresses of the chairs and members, which will be helpful if you want additional information.

The Finance Committee

Bo Norrving

The Finance Committee is chaired by Prof. Bo Norrving. He is senior professor in neurology and a consultant neurologist at Lund University Hospital in Sweden. He has been active in several functions in the WFN oven many years. He has a long experience in governance and leadership of scientific societies, including being president of the World Stroke Organization.

The Finance Committee has several experienced members with a global representation. The task of the WFN Finance Committee is to regularly review the economic strategies and financial situation of the WFN, functioning as an independent body from the WFN executives. The Finance Committee identifies strengths, weaknesses, opportunities, and threats for the WFN, and tries to look into the future taking the global economic situation, and environmental and political issues into account.

The committee also considers the need for adaptations of WFN educational and training activities related to information technology issues, educational tools, and practical issues. The committee helps to ensure that the WFN has a strategy to maintain an economic corpus that is a sufficient reserve for any upcoming disruptions and other threats. In particular, it is essential to have a sustainable balance to support future core projects (fostering best neurological practices, education, and research) and maintaining reserves in case of a downturn in congress income in the future. For this purpose, the assets are composed of short- to medium-term working capital and a longer-term reserve fund. WFN finances and corporate structure are regularly audited.

Over the years, the views of the Finance Committee and those of the trustees have been in excellent agreement. The committee acknowledges the careful strategic planning that has been in constant function at the WFN leadership over the past decades and continues into the future.

Specialty Group on Neuroepidemiology

Carlos N. Ketzoian

The Specialty Group on Neuroepidemiology is chaired by Prof. Carlos N. Ketzoian, neurologist, epidemiologist, and neurophysiologist from the Neuroepidemiology Section, Institute of Neurology, University Hospital, School of Medicine, Montevideo, Uruguay. (carlosk@mednet.org.uy). He has been chairing and researching in several neuroepidemiology activities, is the past-president of the Pan American Society of Neuroepidemiology, and participates in national and international scientific activities. He is also a member of the editorial board of neuroepidemiology.

The Specialty Group on Neuroepidemiology has a long history in the WFN. The proceedings of the group are oriented toward activities of teaching, research, and presentation of neuroepidemiologic results in academic activities, either in the congresses of the WFN or in congresses in different regions such as the Pan American Congresses of Neurology and Pre-Congress Symposia organized by the Pan American Society of Neuroepidemiology.

At the WCN 2021, a scientific session on neuroepidemiology will take place themed “The impact of socio-demographic, economic, and cultural factors on the epidemiology of neurological disorders (WFN Specialty Group on Neuroepidemiology)” on Oct. 6, 2021, in Rome, which is now a virtual meeting.

Research courses and projects have been developed for low- and middle-income as well as high-income countries, favoring a North-South interaction and collaboration. This has had a positive impact on the training of human resources in the area of neuroepidemiology.

Future projects will offer neuroepidemiology training activities in low-income countries. The II Latin American Neuroepidemiology Course scheduled for March 2020 has been postponed without a still-confirmed date of completion given the COVID-19 pandemic global situation. The current situation will need adaptation and virtual as well as hybrid courses will need to be implemented. •

Prestigious WFN Medals Announced

These medals will be awarded at World Congress of Neurology 2021.

WFN Medal Service to International Neurology
Prof. Vladimir Hachinski

WFN Scientific Achievement in Neurology
Prof. Jerry Mendell

WFN Meritorious Service Medals
Prof. Donna Bergen and Keith Newton

Munsat Prize for Service to Education
Prof. Erich Schmutzhard

A Neurology and Psychiatry Clinic in Central America

With Suggestions for Starting a Clinic

By Lawrence Robbins, MD

Neurology/psychiatry clinic near Tegucigalpa, Honduras.

Starting the Clinic: The clinic is located within an excellent rural medical center near the main city (Tegucigalpa). Associating with an established medical center has been ideal. Ninety-five percent of the population has no access to neurology or psychiatry. I decided that it was crucial to supply various neurology and psychiatry medications. Locating the clinic relatively close to a big city was important. Close access has allowed me to teach in the public hospital, bring in other physicians, and refer patients for tests, Suggestion: Look for an established, well-run clinic, and locate within proximity to an international airport. This may not be feasible in all locations.

Associating With an Organization: It is difficult to start a clinic completely independently. I have had a close association with a well-established organization that runs our medical center. They provide room and board, and also help with security, transportation, and hiring clinic personnel. Suggestion: If possible, find community support. Establish close ties with an organization as there are many benefits.

Funding: Alas, it takes money. Lots of it. The plan was to establish a not-for-profit, which I did. With more resources, I was able to build out infrastructure, supply additional medications, and hire extra staff. Fundraising is important, but is one of the most difficult aspects of the venture. I am lucky to have a number of generous donors. Suggestion: If possible, start a nonprofit organization. This is vital for fundraising.

Staff of the neurology/psychiatry clinic.

Personnel: I began with myself, one chart, and one patient. Over time, we have added two psychiatrists and two neurologists, a nurse administrator, and a psychotherapist. We pay the staff approximately what they would make working in their own private practice. The Honduran physicians are young and idealistic. Networking in neurology and psychiatry circles within the country helped me to connect. Connecting with the local neurology/psychiatry societies has been helpful. Neurologists and psychiatrists are in relatively short supply. The Honduran physicians are excellent, but often underpaid. I occasionally bring in another physician from the United States with me. This is usually a rewarding experience. The nurse administrator is a major key to success. The nurse administrator handles recruitment of patients, scheduling, managing patients in the clinic, medications, and other tasks. Suggestion: An administrator, preferably a nurse, is an invaluable part of the team. The downside of bringing in other physicians, or other personnel from another country, is that you are (somewhat) responsible for their trip and safety.

Charting: We are on paper charts, which is easy, and we keep a medication flow sheet. Our paperwork is minimal. Some notes are in English (mine), most are in Spanish. Since we treat each other’s patients, it helps if we list our thoughts for future considerations. In the beginning, we did not need medication or diagnosis flow sheets, as there were only one or two notes to review. Over time, after 15 or 20 visits, the need for flow sheets becomes apparent. Suggestion: Try to keep medication and diagnoses flow charts. It is beneficial to develop uniform charting, as multiple providers may be treating the patient.

Clinic Infrastructure: We have built out a neurology and psychiatry suite, along with a small pharmacy. If our budget were smaller, we would share space with the medical center, and minimize testing. We have supplied computers, and installed internet capability. The internet (usually) works, allowing me to research various conditions that I encounter. Books are convenient to store on my phone or laptop. However, it is more efficient to actually have the physical book handy. Suggestion: It is helpful to have a section of the pharmacy dedicated to the neurology clinic. Internet capability is extremely useful.

Recruiting Patients: In our clinic, the nurse administrator is in charge of recruitment. We have informed various medical clinics of our existence. We also placed a number of public service ads on radio. The neurologists and psychiatrists in nearby cities refer patients. Eventually, word of mouth drives most of the new patients. We draw patients from the entire country and surrounding countries. Suggestion: By alerting other clinics of your neurology clinic, word of mouth spreads quickly. It is helpful to let other physicians know about the existence of the clinic.

Our Services: Our primary purpose is to provide diagnosis and treatment for the vast underserved population. In addition, we offer free medications. We provide free blood tests and EEGs as well. Much needed psychotherapy services are offered on a limited basis. Psychotherapists are difficult to come by. In some settings, a layperson may be trained to be an “active listener.” We have run into barriers with providing therapy services. These barriers include stigma, reluctance to divulge personal information in a rural community, and lack of therapists. We provide patients with a safe place and offer emotional support. We are usually patients’ sole access to care. Suggestion: If possible, supplying medications is invaluable. If therapists are not available, training lay people is a possibility.

Medications and Pharmacy: The basic meds we provide include: antidepressants, anticonvulsants, mood stabilizers, migraine meds, and Parkinson’s medications. I decided that levetiracetam would be a mainstay. It is safe and does not require blood tests.

Our small neurology/psychiatry pharmacy is kept locked at all times. Suggestion: Choose medications that are relatively safe and do not require blood tests. If you purchase medications locally, you can often negotiate a better price.

Telemedicine: Since we have equipped the clinic with internet access, we have been able to connect remotely. Technically, it is a bit cumbersome. I am in Chicago with an interpreter but no chart, and the patient sits in Honduras with a nurse. The lack of insurance (and other) paperwork is helpful. These visits are not ideal, but better than no access at all. Suggestion: Telemedicine can work if there is adequate internet access.

Tests: Lab, MRI, EEG, etc: We do a limited number of blood tests. These tests are relatively expensive in Honduras. We are performing 20 EEGs on a monthly basis out of our clinic. This has been extremely helpful, as many epilepsy patients have not had an EEG, or any access to neurology. MRI/CT is expensive and not easy to obtain. However, many patients do pay for their MRI (about two weeks’ salary) and they bring in the films. We try to use as little testing as is feasible. Suggestion: Blood tests are important, and negotiating a better price is worthwhile. Diagnosis and treatment are often determined without advanced imaging.

Emergencies: We occasionally have a patient in status epilepticus or other neurologic emergencies. I am available from the U.S. for advice. WhatsApp works the best for remote communication. We stock the Emergency Room with basic medications (eg, fosphenytoin and diazepam for seizures). There is a Public Hospital in the main city, but transporting patients there is an adventure. There is only one local ambulance, and we need permission to use it. Suggestions: Neurologic advice often proves invaluable to the ER doctors. It helps to provide basic neurologic emergency medications.

Teaching/Publications/Videos: I teach neurology and psychiatry residents in Tegucigalpa. We have written a manual in Spanish on management of headache. This manual was distributed to many of the Honduran physicians. Suggestion: Teaching the local physicians is a rewarding experience. Articles document your experience and may spur others to follow your path. Videos of the clinic bring the clinic and patients to life. The videos can be instrumental for fundraising and promotion.

Acknowledgements: It takes a number of people to make this clinic a success. Our incredible donors have provided the crucial funding All of the personnel in SAN (Honduras) have provided vital support. The Honduras clinic staff and doctors are the mainstay. •

Lawrence Robbins, MD, is an assistant professor of deurology at Chicago Medical School. Lrobb98@icloud.com; Chicagoheadacheclinic.com (Honduras Project Section with videos/blogs)

Neurology Update in Kazakhstan 2021

By Aida Kondybayeva, MD, PhD

Aida Kondybayeva

The International Educational Online Forum: Neurology Update in Kazakhstan was held April 23-24, 2021. Forums of this scale in Kazakhstan are held every two years, and this forum was being held online for the first time. The event was attended by 985 doctors, including neurologists, internists, GPs, rehabilitation specialists, and intensive care specialists from Kazakhstan, Kyrgyzstan, Uzbekistan, Belarus, and Ukraine.

At the first day within the framework of the International Educational Online Forum: Neurology Update in Kazakhstan, the EAN-Day in Kazakhstan was held. This event was held with the joint work of the European Academy of Neurology, Kazakh National Association of Neurologist Neuroscience, and al-Farabi Kazazakh National University.

Welcoming speeches to the participants were given by Prof. Saltanat Kamenova, president of KNANN; Nadezhda Petuhova, chair of the Public Council of the Ministry of Health of the Republic of Kazakhstan; Prof. Raushan Isayeva, director of High School of Medicine, Faculty of Medicine and Health, al-Farabi Kazazakh National University; and Mikhail Mazurchak, vice president of KNANN. They noted the special significance of the EAN-Day in Kazakhstan for all practicing doctors who took part in this event.

The speakers of the EAN-Day in Kazakhstan were Prof. Aksel Siva from the Department of Neurology of Istanbul University, Cerrahpaşa School of Medicine (Istanbul Turkey); Prof. Erik Taubøll from the Department of Neurology Oslo University Hospital (Oslo, Norway); and Prof. Maxwell Simon Damian, Department of Medicine, Cambridge University (Cambridge, UK).

The professors presented reports on the situation with MS, epilepsy, and neuromuscular diseases before and during the COVID-19 pandemic; these presentations aroused great interest among all participants of the event.

Luca Caffaro, the youngest speaker of this event, presented an interesting report on the work of the Residents and Research Fellows Section (RRFS) of the EAN, and on professional development opportunities for young neurologists and residents. EAN-Day in Kazakhstan received positive feedback from all registered participants of the event.

In the second half of the event, workshops were held, in which speakers presented analyses of difficult clinical cases and the possibilities of their resolution. The second day, the forum was no less eventful, and included reports of doctors from Spain (Jerzy Krupinski-Bilecki), Afghanistan (Ayesha Khaideri), Ukraine (Sergey Moskovko), Russia (Dmitry Kasatkin, Evgeny Evdoshenko, and Natalia Khachanova), and Kazakhstan (Gulsum Duschanova, Saltanat Kamenova, Gulnar Kabdrakhmanova, Mikhail Mazurchak, Maksharip Martazanov, Karlygash Kuzhibaeva, Aida Kondybayeva, and Asel Aralbayeva). Topics including MS, pain, neuromuscular diseases, and epilepsy were discussed. •

Aida Kondybayeva, MD, PhD, is a neurologist and chair of the Educational Committee at Kazakhstan National Association of Neurologist “Neuroscience” Institutional Delegate of the European Academy of Neurology from Kazakhstan.

Cerebral Venous Thrombosis After Vaccination Against SARS-CoV-2

With Information on the International Consortium on CVT Registry

By José M. Ferro, MD, PhD

The public and the global medical community have been exposed since early March 2021, both from the media, the official agencies, and the medical literature, to multiple and often contradictory information, concerning the risk of “uncommon” thrombosis occurring after vaccination against SARS-CoV-2. Most of the news concerned the vaccine manufactured by AstraZeneca and more recently the vaccine from Johnson and Johnson/Janssen. The uncommon thromboses were splanchnic and cerebral venous thrombosis (CVT), mostly the latter.

Mass vaccination is currently humanity’s great hope to control the pandemic. Vaccines were developed, tested, and approved in an incredibly fast pace, about one year since the onset of the pandemic. Administration of a vaccine simultaneously to millions of persons in multiple locations of the world was never done before in human history. Not surprisingly, extremely uncommon side effects of the vaccine, which were not detected in randomized trials of hundreds or thousands of subjects, can emerge when a much larger sample of millions is exposed to the vaccine.

COVID-19 Infection and CVT

CVT was known to occur as a rare complication (0.08%) of COVID-19, accounting for 4.2% of all acute cerebrovascular disease occurring during COVID-19 infection. Several case reports, case series, and systematic reviews of CVT associated with COVID-19 infection have been reported since the beginning of the pandemic 1,2. Both a systematic review2 and a large study based on administrative data from a hospital network3 indicate than the incidence of CVT increased with COVID-19 infection.

CVT can be the initial clinical manifestation of the infection, but the majority of CVTs develop within 13 days of onset of COVID-19 symptoms. Recognized risk factors for CVT are present in only one third of the patients. The main pathophysiological mechanism is related to the hypercoagulable state seen in moderate/severe COVID-19 disease. In fact, CVT patients often have very high D-Dimers, low fibrinogen levels, and low platelet counts. The prognosis is less favorable; namely case fatality (40%) is higher than the non-COVID-19 CVT (5-10%). Management is similar, namely on what concerns the use of parenteral heparin in the acute phase of CVT.

Case Reports and Case Series of CVT Occurring After Vaccination Against SARS-CoV-2

The European Medicines Agency (EMA) approved four vaccines against SARS-CoV-2: two mRNA vaccines from Pfizer and Moderna and two adenovirus vector DAN vaccines from AstraZeneca (AZ) and Johnson & Johnson/Janssen (JJ). The AZ vaccine is not yet approved for use in the United States.

Shortly after the onset of mass vaccination with those vaccines in Europe and in several other countries around the world, there were signals and thereafter publications of case reports and small case series of severe CVT occurring in young women within days of vaccination with the AZ vaccine 4-8. The growing number of those events led several countries to contraindicate the AZ vaccine in young and middle-aged adults, despite the total number of signaled cases being low (<200) as well as the estimated absolute risk of CVT (5 per million vaccinated individuals). In April, a small number of similar cases were reported in the U.S. after the JJ vaccine 9, leading the authorities to temporarily pause the use of that vaccine. A few individuals developed immune thrombocytopenia (ITP) 10 without thrombosis after receiving the mRNA vaccines. There are a few CVTs also reported, but the percentage of CVT occurring after mRNA vaccination is much smaller than for the adenovirus vector DNA vaccines

A striking feature of those cases was the high frequency of thrombocytopenia, which is uncommon in pre-COVID-19 CVT (<10% of the cases). Some other patients had only thrombocytopenia, splanchnic venous thrombosis, or hemorrhagic phenomena, or a combination of those, eventually with CVT. Although most of the emphasis has been placed in the thrombocytopenia, the most serious event, which may be fatal, is CVT. CVT is obviously also the most relevant event to the neurology community.

From the published cases and those signaled to the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC), a clinical profile of CVT associated with the AZ vaccine can be extracted:

CVTs occur almost exclusively in women below age 60.
Only about one third has traditional risk factors for CVT, such as thrombophilia or use of estrogenic contraceptives.
CVT occurs up to 20 days after the administration of the first dose of the vaccine.
A high percentage (up to two thirds) has thrombocytopenia; some have high D-Dimers and low fibrinogen.
The clinical picture is often of a malignant CVT, with multiple sinus and veins thrombosis, cerebral hemorrhages and oedema, causing herniation, often requiring decompressive craniectomy, as a live-saving intervention.
The mortality is high (~25%).
Patients with traditional risk factors for CVT do not appear to have an increased risk of CVT after vaccination.

Possible Pathophysiological Mechanisms

Chance association or undetected recent COVID-19 infection are possible, but unlikely, explanations for CVT occurring after AZ and JJ vaccines. They cannot account for the different risk of CVT after each type of vaccine, not for the distinct clinical laboratory profile, as described in the previous section. Moreover, SARS-CoV-2 PCR nasopharyngeal swabs were negative in all the patients, in whom that test was performed (or reported to be performed), and patients only displayed antibodies against the virus spike protein antigen (most probably a vaccine effect) and not against other antiviral antibodies, as expected if they were recently infected.

Shortly after the notice of the first cases of venous thromboses with thrombocytopenia, a group of researchers from Germany, Ontario, and Vienna under the leadership of Andreas Greinacher identified the mechanism of the thrombotic complications of AZ vaccine, which they called “thrombotic thrombocytopenia.” Unfortunately, this label underscores the fact that the main feature of the syndrome is CVT, with the consequent risk of death and disability. Their patients tested positive on a screening platelet factor 4 (PF4)-heparin immunoassay. None of the patients had received heparin before blood for the tests was drawn. Patients also tested positive on a platelet-activation assay in the presence of PF4 independent of heparin. Platelet activation was inhibited by high levels of heparin and immunoglobulin4. They concluded that the vaccine resulted in a rare thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia (HIT). In recent years, it has been recognized that triggers other than heparin (polyanionic medications, infections, surgery) can also cause a HIT-like coagulopathy, which can also be spontaneous. The pivotal observations of Greinacher et al 4 were confirmed by other researchers11. This post-vaccinial entity is now named vaccine-induced prothrombotic immune thrombocytopenia (VIPIT) or vaccine immune thrombotic thrombocytopenia (VITT).

A similar laboratory observation was found in the cases reported after the JJ vaccine. This finding raises the suspicion that the adenovirus vector could be the initial trigger of antibody production. The adenovirus vector carries negatively charged DNA, which binds to the positively charged PF4. An alternative explanation is the strong inflammatory stimulus of the vaccination or cross-reaction of antibodies produced by the vaccine and PF44. RNA is charged positively, so this immune response is unlikely to occur after mRNA vaccines.

Management of Cerebral Venous Thrombosis Occurring After Vaccination Against SARS-CoV-2

The risk of CVT following AZ vaccine being estimated as only five cases per million vaccinated people, it is evident that no randomized trials are possible to inform management decisions. Evidence comes from case series, analogy with HIT management, and expert consensus statements, and therefore is of low quality. Strong recommendations are not possible and the most sensible option is to produce guidance documents that will be periodically updated, as new evidence is produced.

Vaccinated persons should be informed that they may experience a transient headache a few days after vaccination. If the headache persists or is unusually severe, or they have any other neurological symptom, they should seek urgent medical advice. These patients should be examined by a neurologist.

If the clinical picture is suspicious of CVT, cerebral CT with venography or MR with MR venography should be performed to confirm, or not, the diagnosis of CVT. Meanwhile, a complete blood cell count and film, coagulation tests (INR, APTT, fibrinogen, D-Dimers) and COVID antibodies are obtained.

If CVT is confirmed and platelet count is below 150×109/L, VITT is a possibility. However, if the results of coagulation tests, fibrinogen, and D-Dimers are normal, VITT is unlikely, and the patient can be managed accordingly to the current CVT Guidelines12, namely be treated with low molecular or unfractionated heparin in the acute phase.

On the contrary, if any of those tests is abnormal, VITT is suspected and a HIT Elisa test (capable of detecting PF4 antibodies) should be performed. Consultation with a hematologist is advisable to guide on further testing (e.g., functional HIT assays) and discuss management. Meanwhile, platelet transfusions should be avoided, IV immunoglobulin (e.g., 1 mg/kg for 2 days) be administered, and a non-heparin anticoagulant (argatroban, danaparoid, or direct oral anticoagulants) be used instead of heparin4,11. Endovascular treatment of CVT can also be an option.

The International Consortium on CVT Initiative

From the available evidence so far, it is apparent that CVT after SARS-CoV-2 vaccines can be a heterogeneous group of patients. While most appear to have an immune mechanism (VITT), a few other cases may be coincidental, related to the usual CVT risk factors or even to recent COVID-19 infection. Therefore, a detailed analysis of non-selected CVT cases who developed after any COVID-19 vaccination needs to be performed.

The International Cerebral Venous Thrombosis Consortium (ICVTC) is an existing, global collaboration by academic researchers with the primary aim to perform investigator-initiated research on the epidemiology, manifestations, and outcome of patients with CVT.

Currently, 32 hospitals are participating in the consortium and have already collected data of 1,308 patients with CVT, prior to the COVID pandemic. ICVTC recently launched a prospective registry to report clinical manifestations, laboratory findings, management and outcome of patients with CVT after any COVID-19 vaccination. The registry will include CVT patients with radiologically confirmed CVT, with onset of CVT symptoms within four weeks of COVID-19 vaccination, and informed consent. Principal investigator is Jonathan Coutinho from the Amsterdam University Medical Centers (j.coutinho@amsterdamumc.nl).

Conclusion

Medicine should follow the ethical principle of “Primum non nocere” (first do not harm). However, ethics should also be applied with justice. We must consider that the individual risk of CVT following COVID infection is much higher (6x) than that following any anti-SARS-CoV-2 vaccine3, even without considering the indirect effect of the infection through contagium. Therefore, the fundamental message for the public should focus on the urgent need, safety, and confidence on vaccines.

Epidemiological, clinical, and laboratory research will unveil the multiple remaining unanswered questions on the occurrence of CVT after anti-SARS-CoV-2 vaccines. Meanwhile, neurologists and other health care workers must be aware of this very rare complication of the AZ and JJ vaccines. Management of the occasional CVT patient occurring after those vaccines should follow the most recent guidance statements from national13 and international official agencies and from scientific societies14, which are likely to be updated as evidence grows. Inclusion of those cases in the ongoing International Consortium on Cerebral Vein Thrombosis registry is welcome. •

From the Serviço de Neurologia, Centro Hospitalar Lisboa Norte; J Ferro Lab, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa; Lisboa, Portugal. jmferro@medicina.ulisboa.pt

Inclusion Criteria for the International Consortium on CVT Registry

Patients with cerebral venous thrombosis with:

Radiologically confirmed CVT
Onset of CVT symptoms within 4 weeks of any COVID-19 vaccination
Informed consent, according to local law

For more information, contact Dr. Jonathan Coutinho at j.coutinho@amsterdamumc.nl.

References

Dakay K, Cooper J, Bloomfield J, Overby P, Mayer SA, Nuoman R, Sahni R, Gulko E, Kaur G, Santarelli J, Gandhi CD, Al-Mufti F. Cerebral Venous Sinus Thrombosis in COVID-19 Infection: A Case Series and Review of The Literature. J Stroke Cerebrovasc Dis. 2021 Jan;30(1):105434. doi: 10.1016/j.jstrokecerebrovasdis.2020.105434
Baldini T, Asioli GM, Romoli M, Carvalho Dias M, Schulte EC, Hauer L, Aguiar De Sousa D, Sellner J, Zini A. Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. Eur J Neurol. 2021 Jan 11:10.1111/ene.14727. doi: 10.1111/ene.14727
Taquet M, Husain M, Geddes JR, Luciano S, Harrison PJ. Cerebral venous thrombosis: a retrospective cohort study of 513,284 confirmed COVID cases and a comparison with 489,871 people receiving a COVID-19 mRNA vaccine. In press
Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med. 2021 Apr 9. doi: 10.1056/NEJMoa2104840
Castelli GP, Pognani C, Sozzi C, Franchini M, Vivona L. Cerebral venous sinus thrombosis associated with thrombocytopenia post-vaccination for COVID-19. Crit Care. 2021 Apr 12;25(1):137. doi: 10.1186/s13054-021-03572-y
Schultz NH, Sørvoll IH, Michelsen AE, Munthe LA, Lund-Johansen F, Ahlen MT, Wiedmann M, Aamodt AH, Skattør TH, Tjønnfjord GE, Holme PA. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021 Apr 9. doi: 10.1056/NEJMoa2104882
Mehta PR, Mangion SA, Benger M, Stanton BR, Czuprynska J, Arya R, Sztriha LK. Cerebral venous sinus thrombosis and thrombocytopenia after COVID-19 vaccination – a report of two UK cases. Brain Behav Immun. 2021 Apr 12:S0889-1591(21)00163-X. doi: 10.1016/j.bbi.2021.04.006
Muir K-L, Kallam A, Koepsell SA, Gundabolu K. Thrombotic Thrombocytopenia after Ad26.COV2.S Vaccination. N Engl J Med. 2021 Apr 14. doi: 10.1056/NEJMc2105869.
Franchini M, Testa S, Pezzo M, Glingani C, Caruso B, Terenziani I, Pognani C, Bellometti SA, Castelli G. Cerebral venous thrombosis and thrombocytopenia post-COVID-19 vaccination. Thrombosis Research (2021), https://doi.org/10.1016/j.thromres.2021.04.001
Lee EJ, Liu X, Hou M, Bussel JB. Immune thrombocytopenia during the COVID-19 pandemic. Br J Haematol. 2021 Apr 14. doi: 10.1111/bjh.17457
Scully M, Singh D, Lown R, Poles A, Solomon T, Levi M, Goldblatt D, Kotoucek P, Thomas W, Lester W. Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021 Apr 16. doi: 10.1056/NEJMoa2105385.
Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, Aguiar de Sousa D, Stam J; European Stroke Organization European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis – endorsed by the European Academy of Neurology. Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381
Pai M, Grill A, Ivers N, et al. Vaccine-induced prothrombotic immune thrombocytopenia VIPIT following AstraZeneca COVID-19 vaccination: lay summary. Science Briefs of the Ontario COVID-19 Science Advisory Table. 2021;1(16). https://doi.org/10.47326/ocsat.2021.02.16.1.0
Oldenburg J, Klamroth R, Langer F, Albisetti M, von Auer C, Ay C, Korte W, Scharf RE, Pötzsch B, Greinacher A. Diagnosis and Management of Vaccine-Related Thrombosis following AstraZeneca COVID-19 Vaccination: Guidance Statement from the GTH. Hamostaseologie. 2021 Apr 1. doi: 10.1055/a-1469-7481

President Praises WFN Performance During the Pandemic

By Prof. William Carroll, WFN President

William Carroll, MD

Against the backdrop of what is without a doubt medical history – the vaccination of the world against SARS-Cov-2 virus (COVID-19) – it is appropriate to review our performance. That the vaccination rollout is bumpy is to be expected. That the world has developed a multitude of vaccines and that the process is under way in just over a year is outstanding.

What about the WFN? This assessment of the WFN is focused on the component parts of our organization rather than by overall achievement. In so doing, I hope to illustrate the effort and output of each.

Member Societies
Regional Organizations
Individuals
Related Organizations
London Office
Trustees

It is my personal perspective, and any errors or omissions are mine.

Member Societies

The member societies are the neurological bodies representing neurologists in each jurisdiction and are the core of the WFN. All have had to deal with the impact of the pandemic on their organization, function, and educational activities. In most instances, they have been successful. Members have continued to serve and care for neurological disorders, be involved in educational activities and training, and in many cases supported the World Brain Day campaign of 2020 and the first electronic Annual General Meeting of the Council of Delegates. Collectively, these efforts have assisted the WFN’s mission to foster brain health and quality neurology worldwide.

Member societies are the neurological bodies representing neurologists in each jurisdiction and are the core of the WFN.

117 of 122 member societies responded to the Needs Registry.

In addition, member societies have participated in the program to update communicability with the London Office, an essential element for our global organization. During this program, they have engaged in Zoom conversations to communicate their views on WFN activities and how they might be further engaged.

A pleasing 117 societies responded to the Needs Registry, which will provide data for the development of targeted campaigns to improve services and resources in all socioeconomic strata. Member societies in Africa and Mexico have, where possible, maintained WFN Training Programs.

Some member societies have seized the opportunity presented by the pandemic to upgrade their electronic educational program. Especially notable has been the efforts of the Indian Academy of Neurology in its highly regarded neuroinfections series of 2020, where it partnered with the Tropical and Geographical Neurology Specialty Group.

More recently, the IAN has begun a series highlighting the contribution made by inspiring leaders in neurology. (Please see WFN website.)

Regional Organizations

These six organizations through their presidents have attended the biennial WFN Strategy Meeting in 2020 at the time of the onset of the pandemic. Most of the six have continued their regular congresses.

Most of the six regional organizations have continued their regular congresses.

The EAN and AAN held successful virtual congresses in 2020 and plan to do so again in 2021. Both have also maintained close organizational ties through regular leadership meetings with the WFN.

The AOAN had to defer its 17th Congress from August 2020. It held a successful, highly regarded meeting in early April 2021, which was the first regional hybrid meeting. AFAN has deferred its scheduled biennial meeting from 2021 to October 2022 to be held in Cameroon.

With the WFN, AFAN held a valuable e-Learning Day on stroke in 2020, which included two parallel sessions in French. A similar e-Learning Day will be held in November 2021 on epilepsy.

PAUNS held its biennial Congress in February 2020 (at the onset of the pandemic) and will do the same in 2022.

PAFNS held its Congress in conjunction with the Brazilian Academy of Neurology in 2019 and plans its next congress for 2023.

Regional organizations are supporting efforts by a subgroup of trustees and office staff to improve communications.

Individuals

Neurologists are the core of each member society and the advocates and supporters for them and the WFN. They continue to participate in all regular activities of diagnosis, treatment, and care. In a number of instances, neurologists and neurological infrastructure have been drafted to COVID duties.

Many individuals have made, and are continuing to make, important contributions to national, regional, global, and disease-specific COVID-19 data collection efforts on topics ranging from the impact of COVID-19 on the provision of neurological services generally, the documentation of neuro-COVID phenotypes, and contributed to the development of the WHO Case Report Form to provide more uniform data collection. Many have also participated in activities overseen by the WHO Neuro-COVID Global Forum, the COVID-19 Neuroresearch Coalition, the EAN ENERGY Registry, the NINDS NeuroCOVID project, and the WFN Environmental Neurology Specialty Group’s list of registries.

Many neurologists continue to make important contributions to COVID-19 data collection and maintain neurological services.

Related Organizations

Members of the Global Neurology Alliance (GNA) have supported the WFN World Brain Day campaigns, especially the International Parkinson’s Disease and Movement Disorder Society (2020) and the Multiple Sclerosis International Federation (2021). Recently, GNA members have played a major role in the constructive assessment and advice to the WHO on its discussion plan for the preparation of the Intersectoral Global Action Plan for Epilepsy and Neurological Disorders. Notable here were the International League Against Epilepsy (ILAE,) International Bureau for Epilepsy (IBE), International Child Neurology Association (ICNA), World Stroke Organization (WSO), International Headache Society (IHS), the International Parkinson’s Disease and Movement Disorder Society (IPD&MDS), Alzheimer’s Disease International (ADI), the World Federation of Neuro-Rehabilitation (WFNR), World Psychiatry Association (WPA), and Multiple Sclerosis International Federation (MSIF).

A number of WFN Specialty Groups have also made valuable contributions to the WFN goals. I have already mentioned the Tropical and Geographical Neurology Specialty Group’s series on neuroinfections where they partnered with the Indian Academy of Neurology. The Migrant Neurology Specialty Group has produced an excellent comprehensive reference book on “Neurology for Migrants.”

The Rare Neurological Diseases Specialty Group is conducting a survey on these and their resourcing around the world. The new ALS/MND Diagnostic Criteria were published by the ALS/MND Specialty Group, and the Neuromuscular Disease Specialty Group held its 2020 Congress virtually.

London Office

If member societies are the core of the WFN, the London office is the heart. The WFN employed a second senior manager, Kimberly Karlshoej, in February 2020 with the primary role of overseeing new WFN initiatives, such as the Needs Registry and enhancing the relationship between the WFN and the WHO.

Within weeks, she joined the other London staff in lockdown. Despite the tribulations of the pandemic on London residents, the office staff have exceeded everyone’s expectations, including their own. They have maintained the routine day-to-day management of the federation, such as receiving and responding to email from member societies, calendar organization, financial, and membership records.

Where necessary, they have joined conference calls and provided audio recording for the production of accurate minutes despite an array of different time zones through countless Zoom, GoTo, Teams, and Webex meetings.

They guided a flawless Council of Delegates Annual General Meeting, including the inaugural electronic trustee election. They have orchestrated improved electronic communicability with member societies, specialty groups, WFN committees, and the Global Neurology Alliance, increased the social media posts, and assisted the regular website updates, including the COVID-19 and World Neurology page. These tasks, and there are many that I may have omitted, have all been performed with a cheerful professional disposition which has facilitated business operations in this unprecedented environment. I am sure I speak for all the trustees when I say that we are indebted to our office.

The London Office guided a flawless 2020 Council of Delegates Annual General Meeting, including the inaugural electronic trustee election.

The most important initiative they have been engaged in is the updating of member society contacts and the development of its enduring continuity.

Trustees

The pandemic began one month after the 2020 Trustees and Regional Presidents’ Strategy Meeting. At this time, Jean Marc Leger stepped down as co-opted trustee, and his place was taken soon after by Marianne de Visser. Both Leger and de Visser added invaluable depth to trustee discussions and decisions.

The expiration of Riadh Gouider’s stellar term as trustee at the 2020 AGM was also marked by the election of Morris Freedman. Freedman has begun to develop a WFN e-learning pilot program. Gouider continues to oversee the WFN/AFAN e-learning Day. Throughout 2020 and to date, each and every one of the trustees have combined energetically in the collective effort of the WFN. All have recognized the importance that they represent all member societies, and that decisions made by them, as trustees, are all gauged by their worth for the whole federation.

Trustees all recognize that they represent all member societies and that decisions made by them are gauged by their worth for the whole federation

It has been a pleasure to witness the careful consideration given by all in discussing a matter of weight before arriving at the most optimal decision. I have no doubt that the present composition of four officers, three elected trustees, and two co-opted trustees is the most efficient for a number of reasons.

First, a nine-person group is simply workable. Each can contribute readily both in discussion and in the preparation of papers for specific proposals. Second, the ability to co-opt two trustees provides flexibility for particular skillsets and diversity. Third, the staggered rotation of the elected trustees provides additional corporate memory to that of the executive officers. Fourth, a board of nine persons is a number that the London office can support efficiently. An increased number would likely require an increase in staff. Leanness and flexibility are two desirable virtues on which the WFN depends.

Current trustee structure is fit for purpose.

A nine-person group is simply workable. Each can contribute readily both in discussion and in the preparation of papers for specific proposals.
The ability to co-opt two trustees provides flexibility for particular skillsets and diversity.
The staggered rotation of the elected trustees provides additional corporate memory to that of the executive officers.
A board of nine persons is a number that the London office can support efficiently.

Conclusion

I am then unashamedly proud of the WFN and its robust advancement on all fronts despite the COVID-19 pandemic. As I have tried to illustrate above, every part of the organization, its governance, and the processes have performed admirably. I, as the president, and we all as the WFN, know that from individual neurologists, who have continued to function as neurologists in the care of people with neurological illness, through to the London office should share a sense of achievement for what has been done.

There is still some way to go to a post-COVID normal but we can appreciate that we will continue to prosecute our mission to foster brain health and quality neurology through and beyond the end of this pandemic. •

Letter from the editors

Steven L. Lewis, MD, Walter Struhal, MD

Welcome to the April 2021 issue of World Neurology. This issue begins with the President’s Column, where WFN President William M. Carroll thoroughly reviews the performance of the WFN during the pandemic. Next, Dr. Jose M. Ferro provides an extensive and authoritative update on the status of cerebral venous thrombosis (CVT) and vaccination against SARS-CoV-2, and provides important information on the International Consortium on CVT Registry.

Also in this issue, WFN Vice President Ryuji Kaji informs us of the decision and news that the WCN 2021 will be a fully virtual congress, and he updates us on the planning and fee structure for this important and exciting event, for which a tremendous number of abstracts have been received.

In this issue’s column on the WFN Committees and Specialty Groups, WFN Secretary-General Wolfgang Grisold, James L. Bernat, and Tissa Wijeratne report on the many activities of the WFN Public Awareness & Advocacy Committee and the important activities of the newly reconvened Neuroethics Specialty Group chaired by Dr. Bernat.

Tissa Wijeratne, Wolfgang Grisold, Rachel King, and William Carroll announce the topic of this year’s World Brain Day (WBD 2021), devoted to the topic of multiple sclerosis and being held jointly with the Multiple Sclerosis International Federation (MSIF). In this issue’s report from the Journal of the Neurological Sciences, Editor-in-Chief John D. England announces the publication of the Special Issue on Tropical Neurology, an issue of importance to neurologists worldwide.

In this issue’s WFN Training Center report, Dr. Lawrence Tucker, head of the division of Neurology at the University of Cape Town, reports on the new WFN Training Center at Grote Schuur and Tygerberg Hospitals, and the arrival of the first WFN sponsored trainee from Ghana.

In the history column, Peter J. Koehler details the intriguing historical underpinnings of tabes dorsalis and the Romberg test. Dr. Stefan Oberndorfer provides a concise update on cancer therapy and neurotoxicity.

Drs. Chandrashekhar Meshram, JMK Murthy, Nirmal Surya, and U. Meenakshisundaram report on the successful public awareness event held in India in collaboration between the Tropical and Geographical Neurology Specialty Group of the WFN and the Indian Academy of Neurology (IAN) to celebrate the Brain Health initiative to raise awareness for the importance of brain health. Finally, in this issue’s Department Visit Report, Dr. Ani-Osheky Ifeyinwa from Nigeria reports on her pre-pandemic visit to the neurology department of the Selçuk University in Konya, Turkey.

Thanks again to all of our readers for your interest in World Neurology. We look forward to continued submissions from neurologists and neurological societies from around the world to inform all neurologists about the many activities, events, and opportunities you create to enhance the field of neurology and neurologic health. •

The Format of World Congress of Neurology 2021 in Rome Finalized

By Ryuji Kaji, Chair Congress Committee, First Vice President of the WFN

Ryuji Kaji

The Congress Committee met on April 19, and the format of WCN2021 was finalized. Considering the global outlook of the COVID-19 pandemic and the decisions of other international meetings, we had to conclude that WCN2021 shall be held all online.

Despite being fully virtual, we will try our best for all of the participants to amply experience the atmosphere of Rome using state-of-the-art technology. The registration fee was revised and discounted to a large extent to facilitate attendance of many delegates, young neurologists, and medical students (see box at right), and the contents will be held available on the web for three months after the meeting for the registered participants.

The deadline of abstract submission was May 3, and we received over 2,000 abstracts. More bursaries than usual (200) will be provided to encourage young neurologists in the form of waiving registration fees. The early registration fees will apply until July 13, and we sincerely ask more neurologists than ever to make our virtual meeting one of the best WCNs in the new style of holding an academic meeting during the pandemic.

We are also soliciting nominations of the names for WFN medals for 2021 ( https://wfneurology.org/activities/education-grants-and-awards/wfn-awards ).

See you all virtually in Rome! •

Registration Fees	Euros
Full Participants Int’l – Early	300
Full Participants Int’l – Late	350
Full Participants – Italians Early	200
Full Participants – Italians Late	250
Low/Lower Middle Income Countries – Early*	150
Low/Lower Middle Income Countries – Late*	200
Allied Health Professionals – Early + Late **	100
Undergraduate Medical Students – Early + Late **	Waived

Low/Lower Middle Income countries are defined according to the World Bank Country Classification. Participants from Low/Low Middle Income Countries must submit a copy of their passport *Allied Health Professionals include Residents, Fellows, Nurses, Physical Therapist, Occupational Therapist, and Speech Therapist. Status must be certified by an official letter from the institution signed by the head of the department

Special Issue on Tropical Neurology

By John D. England, MD

John D. England, MD

During the World Congress of Neurology in 2017 in Kyoto, Japan, Profs. Marco Medina, Chandrashekar Meshram, Raad Shakir, and I proposed to publish a special issue on tropical neurology in the Journal of the Neurological Sciences. The selection of topics and authors was coordinated with the Tropical and Geographical Specialty Group of the World Federation of Neurology (WFN). Because of the high incidence and prevalence of neglected tropical diseases (NTD) that affect the nervous system, this project was given high priority by the journal’s editorial board.

Almost half of the world’s population (approximately 3.3 billion) resides in the tropics. Taken together, NTDs affect close to 1 billion people each year. At present, these diseases affect the majority of Latin America, Asia, and Africa. Due to global climate change, these diseases are predicted to affect an ever-increasing number of people. We hope this special issue will bring greater attention to these important and highly prevalent diseases.

Because the special issue is an online product, articles are added as they are accepted for publication. Currently, nine articles covering the topics of CNS fungal infections, onchocerciasis, ebola, chikungunya, leprosy, tuberculosis, brucellosis, COVID-19, and environmental neurology are published; others covering neurocysticercosis, dengue, and zika will follow.

The articles in the special issue are available by accessing:

https://www.sciencedirect.com/journal/journal-of-the-neurological-sciences/special-issue/10NG1VC7F2Z •

John D. England, MD, is editor-in-chief of the Journal of the Neurological Sciences, the official journal of the WFN.

The WFN Public Awareness & Advocacy Committee and the Neuroethics Specialty Group

By Wolfgang Grisold, James L. Bernat, and Tissa Wijeratne

Wolfgang Grisold

In this edition of World Neurology, we will continue to present one committee and one specialty group, to explain the various activities of the WFN. In short, and as a wrap-up from the previous articles, the WFN has committees, which are dedicated to specific tasks, and 16 specialty groups, formerly known as Applied Research Groups, which are working groups dedicated either to specific health issues and diseases or to other relevant topics.

In this issue, we introduce the WFN Public Awareness & Advocacy Committee, which has the important agenda to organize World Brain Day, among others, and from the Specialty Groups, the Neuroethics specialty group, which has been newly activated and composed.

For details, please see Committees at https://wfneurology.org/about-us/committees and Special Groups ( SG) at https://wfneurology.org/about-us/global-networks/wfn-specialty-groups.

WFN Public Awareness & Advocacy Committee

Tissa Wijeratne

Prof. Tissa Wijeratne chairs this committee and the complete list of members is on the website. Prof. Wijeratne is the chair of the Department of Neurology, Sunshine Hospital, Western Health, Faculty of Medicine, Melbourne Medical School, Sunshine Campus, St Albans, Victoria, Australia (https://whcda.wh.org.au/research/neurology-research/). He has recently been appointed as the editor in chief of neurology international, MDPI with a special collection on advocacy in neurology and brain health.

The important task of advocacy and public awareness is to raise public awareness of neurological disorders. The World Federation of Neurology was established on July 22, 1957. The Public Awareness and Advocacy Committee suggested that July 22, 2014, should be celebrated as World Brain Day (WBD). This proposal was announced at the World Congress of Neurology Council of Delegates meeting in Vienna on Sept. 22, 2013, and the proposal was received with a warm welcome by delegates. The Board of Trustees meeting in February 2014 endorsed this proposal as an annual and ongoing activity.

The main objective of WBD is to increase public awareness and promote advocacy related to brain health. The theme for the 2014 WBD campaign was “Our Brain, Our Future.” The WBD 2015 campaign was dedicated to epilepsy (with the International League Against Epilepsy). The 2016 WBD campaign was “Brain Health and the Aging Population,” and the 2017 WBD campaign was dedicated to stroke (with the World Stroke Organization). The WBD 2018 topic was “Clean Air for Brain Health” (with the Specialty Group on Environmental Neurology). WBD 2019 was dedicated to migraine (with the International Headache Society), and WBD 2020 was devoted to ending Parkinson’s disease (with the Movement Disorders Society). WBD 2021 will be “Halt Multiple Sclerosis.”

The committee is responsible for the WBD campaign under the leadership of the trustees, the secretary-general, and the WFN president. The committee collaborates with the regional associations, including the African Academy of Neurology, the American Academy of Neurology, the Asian and Oceanian Association of Neurology, the European Academy of Neurology, the Pan-American Federation of Neurological Societies (PAFNS), the Pan Arab Union of Neurological Societies, and national neurology member societies, to raise awareness among neurological disorders with a successful WBD campaign year after year.

The committee is keen to promote the brain health initiative and public awareness campaigns to promote better awareness and advocacy for neurological disorders globally.

Neuroethics Specialty Group

James L. Bernat

This group is chaired by Prof. James L. Bernat. He is professor of neurology, active emeritus and former Louis and Ruth Frank Professor of Neuroscience at the Dartmouth Geisel School of Medicine in Hanover, New Hampshire. He is the author of Ethical Issues in Neurology, 3rd edition (Philadelphia: Lippincott Williams & Wilkins, 2008).

Neuroethics Specialty Group Resumes Work

In November 2019, the former WFN Ethics Specialty Group was reborn as the Neuroethics Specialty Group. Under the leadership of James Bernat, members include Ralf Jox (Switzerland), Adam Zeman (U.K.), and Alejandro Serani Merlo (Chile). The WFN Ethics Specialty Group previously had operated under the leadership of Prof. Franz Gerstenbrand (Austria) until his death in 2017.

The Neuroethics Specialty Group has identified several activities. They created a neuroethics teaching course for the WCN 2021 meeting in October that will be offered on the first day. Dr. Eelco Wijdicks (USA) will speak on the ethical issues in brain death, and Dr. James Bernat will speak on the ethical issues of physician-assisted death and active euthanasia. Dr. Bernat is also working with Dr. Sabahat Wasti (UAE), the chair of the Neuroethics Special Interest Group of the World Federation of Neurorehabilitation, to develop a teaching conference on neuroethics for the meeting.

The Neuroethics Specialty Group supported the World Brain Death Project, a 5-year effort to generate international consensus on brain death, composed of dozens of investigators, led by Gene Sung (USA), David Greer (USA), and a steering committee. Although the project did not originate in the WFN, it had been a longstanding idea of Prof. Franz Gerstenbrand that he had discussed with Dr. Bernat in Vienna at the WCN 2013.

The World Brain Death Project report was endorsed by the WFN and 30 other neurological, neurosurgical, and critical care societies around the world [see Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurological criteria: The World Brain Death Project. JAMA 2020;324:1078-1097, plus 17 supplements accessible on-line.]

The worldwide consensus developed in the World Brain Death Project represented an international group of leading neurologists, neurosurgeons, and intensivists but acknowledged that a minority of professionals in different countries oppose brain death for scientific, conceptual, ethical, religious, or cultural reasons.

The Neuroethics Specialty Group is considering initiating projects. Given their small size, they feel that the best use of their expertise will be collaborative: to offer ethical guidance to other specialty groups as they pursue their endeavors.

Some ideas raised by members at the February 2021 Specialty Group meeting included:
the ethical issues in incorporating personalized medicine into neurological practice
the inherent ethical limitations on protecting patient privacy and confidentiality in genomic medicine
the ethical issues raised in global access to neurological care the evolving global changes in assisted dying practices for neurological patients
the role of individual differences in humans as a source of interpersonal conflict.

Presently, the Neuroethics Specialty Group is recruiting additional members, particularly from Asia and Africa. If WFN members have suggestions for new specialty group members or topics for the Neuroethics Specialty Group to address, please contact Dr. James Bernat at bernat@dartmouth.edu. •