Background Several studies have demonstrated reduced serological response to vaccines in patients treated with anti-CD20 agents. However, limited data exist surrounding the clinical effect of disease modifying therapy (DMT) use on vaccine efficacy. Objectives To investigate breakthrough coronavirus disease 2019 (COVID-19) in vaccinated people with multiple sclerosis (PwMS) on DMT. Methods PwMS on DMT diagnosed with COVID-19 after full vaccination were identified from an existing Cleveland Clinic COVID-19 registry, supplemented by provider-identified cases. Demographics, disease history, DMTs, comorbidities, exposures, vaccination status, and COVID-19 outcomes were confirmed by review of the electronic medical record. Results Thirteen (3.8%) of 344 fully vaccinated people with multiple sclerosis on disease modifying therapy were diagnosed with COVID-19 after vaccination. Ten patients (76.9%) were on an anti-CD20 therapy, the remaining 3 (23.1%) on fingolimod. Only 2 patients (15.4%), both on anti-CD20 therapy, required hospitalization and steroid treatment. Neither required Intensive Care Unit admission. Conclusion Patients treated with anti-CD20 agents and sphingosine 1-phosphate receptor modulators may still be at risk for COVID-19 despite vaccination. While still at risk for hospitalization, intubation and death from COVID-19 appear rare. Larger studies analyzing how this may differ in the setting of emerging variants are needed.

Background and objectives:Although the international community collectively seeks to reduce global temperature rise to under 1.5ºC before 2100, irreversible environmental changes have already occurred, and as the planet warms these changes will continue to occur. As we witness the effects of a warming planet on human health, it is imperative that neurologists anticipate how the epidemiology and incidence of neurologic disease may change. In this review, we organized our analysis around three key themes related to climate change and neurologic health: extreme weather events and temperature fluctuations, emerging neuro-infectious diseases, and pollutant impacts. Across each of these themes, we appraised and reviewed recent literature relevant to neurological disease and practice.Methods:Studies were identified using search terms relating to climate change, pollutants, and neurologic disease in PubMed, OVID MEDLINE, Embase, PsycInfo, and grey literature. Studies published between 1990 and 2022 were included if they pertained to human incidence or prevalence of disease, were in English, and were relevant to neurologic disease.Results:We identified a total of 364 articles, grouped into the three key themes of our study; extreme weather events and temperature fluctuations (38 studies), emerging neuro-infectious diseases (37 studies), and pollutant impacts (289 studies). The included studies highlighted the relationships between neurologic symptom exacerbation and temperature variability, tick-borne infections and warming climates, and airborne pollutants and cerebrovascular disease incidence and severity.Discussion:Temperature extremes and variability both associated with stroke incidence and severity, migraine headaches, hospitalization in dementia patients, and multiple sclerosis exacerbations. Exposure to airborne pollutants, especially PM2.5 and nitrates, associated with stroke incidence and severity, headaches, dementia risk, Parkinson’s disease, and MS exacerbation. Climate change has demonstrably expanded favorable conditions for zoonotic diseases beyond traditional borders, and poses the risk of disease in new, susceptible populations. Articles were biased towards resource-rich regions, suggesting a discordance between where research occurs and where changes are most acute. As such, three key priorities emerged for further study; neuro-infectious disease risk mitigation, understanding the pathophysiology of airborne pollutants on the nervous system, and methods to improve delivery of neurologic care in the face of climate-related disruptions.

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Multiple sclerosis (MS) is commonly diagnosed in young adults during their reproductive years. Consequently, concerns about family planning and MS management related to pregnancy and breastfeeding are often encountered in clinical practice. Pregnancy itself is not harmful for women with MS. However, disease-modifying therapies (DMTs) have implications for reproductive planning, including stopping treatment while trying to conceive and during pregnancy, as well as managing fetal risks. People with MS and their care team must engage in collaborative decision-making before, during, and after pregnancy. Based on the results of a consensus-building initiative, answers are provided to 20 frequently asked questions regarding the management of MS during pregnancy planning, pregnancy, and the postpartum period. KEY POINTSMost women with MS can conceive, have normal pregnancies and deliveries, and breastfeed successfully.Primary considerations relate to ensuring proper prenatal counseling about cessation of DMT and timing of conception, as well as resumption of DMT.To engage in collaborative decision-making throughout all stages of pregnancy, clinicians caring for people with MS need to be familiar with pregnancy-related risks associated with MS therapies, as well as the management of MS-related reproductive issues.

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