Immune Checkpoint Inhibitors in Patients with Pre-existing Neurologic Autoimmune Disorders.

PURPOSE OF REVIEW: The use of immune checkpoint inhibitors (ICIs) for oncologic indications is associated with immune-related adverse events (irAEs). Patients with pre-existing autoimmune diseases are at increased risk of irAEs and have largely been excluded from clinical trials of ICIs. Therefore, there is limited data on the safety of safety of ICIs in patients with pre-existing neurologic autoimmune diseases (nAIDs) such as myasthenia gravis and multiple sclerosis. This review aims to synthesize the literature on the post-marketing experience with ICI in patients with pre-existing nAID and to discuss possible strategies for mitigating the risk of post-ICI nAID relapses. RECENT FINDINGS: Patients with pre-existing myasthenia gravis (MG), myositis, and paraneoplastic encephalitis appear highly susceptible to neurologic relapses of their underlying neurologic disorder following ICI initiation; these relapses can cause considerable morbidity and mortality. In patients with multiple sclerosis (MS), the risk and severity of MS relapses following ICI appears to be relatively lower compared to MG. Preliminary evidence suggests that older MS patients with no recent focal neuroinflammatory activity may be safely treated with ICI. Among the several case reports of ICI in patients with a history of Guillain-Barre syndrome (GBS), neurologic worsening was only recorded in one patient who was in the acute phase of GBS at the time of ICI start. Initiating an ICI in a patient with pre-existing nAID involves a complex risk-benefit discussion between the patient, their oncologist, and neurologist. Relevant issues to consider before ICI include the choice of disease-modifying therapy for nAID (if any) and strategies for promptly identifying and managing nAID relapses should they occur. Currently, the literature consists mainly of case reports and case series, subject to publication bias. Prospective studies of ICI in patients with nAID are needed to improve the level of evidence.

Sleep Medicine Knowledge Among Graduating Medical Students in Lebanon During an Economic and Political Crisis: A Preliminary Survey.

Objectives Sleep disorders are prevalent and underrecognized during both economic and political crises. They are a major reason for poor overall health and decreased quality of life. Sleep medicine education is limited at most medical schools, resulting in limited awareness of this important aspect of healthcare. The aim of the study is to assess sleep medicine knowledge of graduating medical students in Lebanon and to assess their readiness to tackle sleep health issues in a country during an unprecedented crisis. Methods Final-year medical students at 7 medical schools in Lebanon were invited to fill a survey between January 2020 and March 2021. The Assessment of Sleep Knowledge in Medical Education survey was used to assess their knowledge in sleep medicine. The curriculum organizers at the medical schools were also surveyed. Student's t -test was used for analysis. Results 158 and 58 students completed the survey during 2020 and 2021, with a mean overall score on sleep knowledge of was 17.5 and 15.9 /30, respectively. There was no difference in mean knowledge scores by gender, age, American versus European medical school systems, and between medical schools that included sleep medicine in their curriculum versus those that did not. Conclusions Presence of sleep medicine education in the curriculum was associated with higher scores on ASKME among graduating Lebanese medical students. Given the low response rate, however, this descriptive pilot data could be used as a launching pad for a larger study, with a more representative sample, for generalizable results.

Impact of traumatic brain injury on sleep: an overview.

Traumatic brain injury (TBI) is a global health problem that affects millions of civilians, athletes, and military personnel yearly. Sleeping disorders are one of the underrecognized sequalae even though they affect 46% of individuals with TBI. After a mild TBI, 29% of patients have insomnia, 25% have sleep apnea, 28% have hypersomnia, and 4% have narcolepsy. The type of sleep disturbance may also vary according to the number of TBIs sustained. Diffuse axonal injury within the sleep regulation system, disruption of hormones involved in sleep, and insults to the hypothalamus, brain stem, and reticular activating system are some of the proposed theories for the pathophysiology of sleep disorders after TBI. Genetic and anatomical factors also come to play in the development and severity of these sleeping disorders. Untreated sleep disturbances following TBI can lead to serious consequences with respect to an individual's cognitive functioning. Initial management focuses on conservative measures with progression to more aggressive options if necessary. Future research should attempt to establish the effectiveness of the treatments currently used, as well as identify manageable co-existing factors that could be exacerbating sleep disorders.