Neurology. Clinical practice最新文献

{"title":"Workplace Lactation in Neurology: Barriers and Opportunities.","authors":"Deborah A Hall, Deborah O Setter, Nicole J Ullrich, Lauren E Klaffke, Nicole R Gonzales, Susanne Muehlschlegel, Kiran Teresa Thakur, Annise Wilson, Janis M Miyasaki, Kathleen M Shannon, Elizabeth A Coon","doi":"10.1212/CPJ.0000000000200611","DOIUrl":"10.1212/CPJ.0000000000200611","url":null,"abstract":"<p><strong>Background: </strong>Federal law requires workplaces to provide appropriate space, time, and, when employees are not fully relieved of their duties during breaks, compensation to support pumping at work. The aim of this study was to assess the current landscape for lactating persons in neurology and to identify opportunities for improvement within the workplace.</p><p><strong>Recent findings: </strong>Respondents of a 53-question survey distributed to AAN members reported varying levels of awareness regarding institutional lactation policies. Although most lactating individuals indicated that they had adequate time and space to pump, most were not compensated during their breaks. One-third of respondents stopped pumping earlier than intended, although most did not change jobs because of lactation-related challenges and continued to recommend neurology as a career to students.</p><p><strong>Implications for practice: </strong>Ensuring designated time, appropriate space, and compensation for lactation at both the institutional and individual levels is essential to support early-career neurologists.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200611"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13094750/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147874800","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Long-Term Outcomes of Subthalamic Nucleus and Globus Pallidus Interna Deep Brain Stimulation for Young-Onset Parkinson Disease.","authors":"Grace E Hey, Hikaru Kamo, Gilberto Perez Rodriguez Garcia, Tejas R Mehta, Robert Stephen Eisinger, Michael S Okun, Justin D Hilliard, Kelly D Foote, Adolfo Ramirez-Zamora","doi":"10.1212/CPJ.0000000000200605","DOIUrl":"10.1212/CPJ.0000000000200605","url":null,"abstract":"<p><strong>Background and objectives: </strong>Patients with young-onset Parkinson disease (YOPD) commonly experience early motor complications necessitating deep brain stimulation (DBS), and the subthalamic nucleus (STN) and globus pallidus interna (GPi) are the primary DBS targets used for reducing medication use and addressing dyskinesias. This study leveraged both the University of Florida Fixel Institute high volume of DBS operations and the INFORM database to evaluate motor outcomes in a large cohort of patients with YOPD treated with STN or GPi DBS, and addressed the limited available evidence and paucity of data on the long-term effects of these targets applied to YOPD.</p><p><strong>Methods: </strong>A single-center retrospective chart review was conducted on a nonrandomized cohort of adult patients with a diagnosis of YOPD treated with STN or GPi DBS between January 1999 and October 2023. Multidisciplinary evaluation was used to choose the anatomical target for each patient. Disease onset, lead location, medications, and mortality were collected and compared between cohorts. Preoperative, 6-month, and 1-, 3-, and 5-year Unified Parkinson's Disease Rating Scale (UPDRS) scores were used to compare motor outcomes.</p><p><strong>Results: </strong>There were 405 patients, and 61.3% received GPi DBS and 37.7% STN DBS. Mean disease duration at surgery was 12.3 (4.2) years for GPi and 11.5 (6.3) years for STN. GPi DBS improved ON UPDRS part 3 scores at 1 year (26.5 [11.84] vs 20.94 [9.09], <i>p</i> = 0.0024), and these scores worsened slightly by 5-year follow-up (20.94 [9.09] vs 24.72 [10.28], <i>p</i> = 0.0491). Unilateral STN DBS showed greater 6-month motor improvement vs unilateral GPi (<i>p</i> < 0.001) and remained stable from 6 months to 3 years (<i>p</i> = 0.3). GPi DBS improved ON UPDRS part 4 scores from baseline to 5 years (8.34 [3.15] vs 4.21 [2.25], <i>p</i> < 0.0001), whereas STN DBS showed no significant change (6.16 [4.21] vs 5.0 [2.98], <i>p</i> = 0.328). Although statistically significant, the changes did not meet the threshold for clinical relevance.</p><p><strong>Discussion: </strong>This large cohort study assessed long-term outcomes of STN vs GPi DBS when used in the setting of YOPD. Both targets improved motor symptoms at 1 and 5 years. STN offered modest motor benefits and greater medication reduction, while GPi DBS better addressed dyskinesia and motor fluctuations. These findings inform preoperative decision-making, although selection bias based on baseline symptoms remains a limitation of the data set.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200605"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020557/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147574413","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Uncoupling Relapse Reduction and Disability Progression: Evidence From Tolebrutinib Studies.","authors":"Alessio Signori, Noemi Montobbio, Francesca Bovis, Marta Ponzano, Irene Schiavetti, Alessandra Krenn, Maria Pia Sormani","doi":"10.1212/CPJ.0000000000200612","DOIUrl":"10.1212/CPJ.0000000000200612","url":null,"abstract":"<p><strong>Objectives: </strong>The aim of this study was to evaluate whether the treatment effects of tolebrutinib on confirmed disability worsening (CDW) diverge from its effects on relapse prevention compared with other disease-modifying therapies (DMTs) for relapsing multiple sclerosis (MS).</p><p><strong>Methods: </strong>We extracted published effect estimates for annualized relapse rate (ARR) and CDW confirmed at 24 weeks from all phase 3 trials with teriflunomide as the active comparator: ASCLEPIOS (ofatumumab), OPTIMUM (ponesimod), ULTIMATE (ublituximab), EVOLUTION (evobrutinib), and GEMINI (tolebrutinib). When duplicate trials were available, pooled estimates were derived. Log-transformed estimates were used in a weighted linear regression of CDW vs ARR, with bubble size reflecting statistical precision. Tolebrutinib was excluded from the regression fit but displayed for comparison.</p><p><strong>Results: </strong>Across 4 DMTs other than tolebrutinib, a strong linear association was observed between treatment effects on ARR and CDW (R² = 0.997), indicating that disability benefit was generally proportional to relapse reduction. By contrast, tolebrutinib deviated from this relationship, with a hazard ratio for CDW of 0.71 (95% CI 0.53-0.95) despite a relapse rate ratio of 1.03 (95% CI 0.85-1.25).</p><p><strong>Discussion: </strong>Tolebrutinib was the only therapy to show a benefit on CDW without a measurable effect on relapses, highlighting a dissociation between disability worsening and relapse suppression not observed with other DMTs.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200612"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13065243/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147874723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Bridging the Funding Gap in Drug Development for Amyotrophic Lateral Sclerosis.","authors":"Pineal Iyassu Bareamichael, Suma Babu, Trang Hoang, Mariana P Socal","doi":"10.1212/CPJ.0000000000200623","DOIUrl":"10.1212/CPJ.0000000000200623","url":null,"abstract":"<p><p>Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with few effective treatments and high clinical trial failure rates. Since 1995, only 3 drugs riluzole, edaravone, and tofersen have gained approval from the Food and Drug Administration, all offering modest benefits. Challenges in ALS drug development include poor translational preclinical models, underpowered early-phase trials, and the high cost of late-stage development. Despite federal initiatives such as the Accelerating Access to Critical Therapies for ALS Act and the ALL ALS Consortium, critical gaps remain in funding large multisite trials and sustaining research networks. Accelerating progress requires strengthening national registries, expanding adaptive trial platforms, integrating existing networks, and adopting innovative funding models such as milestone-based public-private partnerships and reinvestment of licensing revenues. A coordinated, sustainable research and funding ecosystem could transform ALS therapy development and serve as a model for advancing treatments for other rare neurodegenerative and neurogenetic disorders.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200623"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13155693/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147875296","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparative Accuracy of TCD, TTE, TEE, and Cardiac CT in Detecting Right-to-Left Shunt in Embolic Stroke of Undetermined Source.","authors":"Vikas Ravi, Yasaman Pirahanchi, Seyed Behnam Jazayeri, Emma Rice, Dawn M Meyer, Kunal Agrawal, Royya Modir, Thomas Hemmen, Brett C Meyer, Reza Bavarsad Shahripour","doi":"10.1212/CPJ.0000000000200604","DOIUrl":"10.1212/CPJ.0000000000200604","url":null,"abstract":"<p><strong>Background and objectives: </strong>Identifying a right-to-left shunt (RLS), commonly due to a patent foramen ovale (PFO), is essential in evaluating embolic stroke of undetermined source (ESUS). While several imaging modalities are used for PFO detection, direct comparisons in a single cohort are limited. This study evaluates and compares the diagnostic performance of 4 major modalities: transcranial Doppler (TCD), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and cardiac CT in patients with ESUS.</p><p><strong>Methods: </strong>We retrospectively identified patients with ESUS referred to our neurosonology laboratory from July 2023 to May 2025, who underwent at least 3 of the 4 diagnostic modalities. A confirmed PFO was defined by concordant positive findings on at least 2 tests. Diagnostic performance metrics (sensitivity, specificity, positive predictive value, negative predictive value [NPV], accuracy, and area under the curve [AUC]) were calculated, with pairwise comparisons assessed using the DeLong test.</p><p><strong>Results: </strong>Of 469 screened patients, 130 met inclusion criteria. TCD showed the highest sensitivity (100%), NPV (100%), and an accuracy of 87.6%, although specificity was moderate at 75.0%. After excluding patients with mild PFO or extracardiac shunts, specificity and accuracy improved to 81% and 90.8%, respectively. TTE achieved a sensitivity of 83.3% and specificity of 93.3%, with an overall accuracy of 88.1%. TEE had a sensitivity of 95.1%, specificity of 87.5%, and the highest overall accuracy at 91.3%. Cardiac CT had perfect specificity (100%) but the lowest sensitivity (45.8%), limiting its standalone diagnostic utility. AUC comparisons revealed superior diagnostic performance for TCD, TTE, and TEE over cardiac CT (<i>p</i> values <0.05), but no significant differences among TCD, TTE, and TEE.</p><p><strong>Discussion: </strong>TCD is a highly sensitive, noninvasive first-line tool for detecting RLS in ESUS, particularly in acute or resource-limited settings. Confirmatory TTE, TEE, or CT can be tailored to context, with a tiered approach optimizing PFO detection and prevention strategies. Results should be interpreted cautiously, given the referral and selection bias. Larger prospective multicenter studies are needed to validate this approach and improve outcomes.</p><p><strong>Classification of evidence: </strong>This study provides Class IV evidence that (1) TCD and TEE were highly sensitive in detecting PFO; (2) TTE and cardiac CT were highly specific in detecting PFO; (3) TCD, TTE, and TEE had superior diagnostic performance over cardiac CT (as defined by AUC comparison analysis); and (4) there were no significant differences in overall diagnostic performance among TCD, TTE, and TEE.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200604"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147574964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Meaningfulness of Donanemab in Early Symptomatic Alzheimer Disease: Data From the Randomized Phase 3 TRAILBLAZER-ALZ 2 Trial.","authors":"Alireza Atri, Liana G Apostolova, Atsushi Iwata, Alette M Wessels, Alexandra Atkins, Ming Lu, Wenyu Ye, Sinéad Ryan, Erin Gautier Doty","doi":"10.1212/CPJ.0000000000200621","DOIUrl":"10.1212/CPJ.0000000000200621","url":null,"abstract":"<p><strong>Background and objectives: </strong>Understanding the meaningfulness of clinical trial outcomes is essential for people living with Alzheimer disease (AD) and their clinicians to make evidence-based shared treatment decisions in real-world clinical care. Donanemab, a monoclonal antibody targeting the insoluble form of β-amyloid found in plaques, significantly slows cognitive and functional decline of AD in participants with mild cognitive impairment (MCI) or mild AD-related dementia. This analysis reviews the efficacy of donanemab across various clinical outcome assessments, using both published data and new complementary analyses to provide context on its potential benefits for patients and caregivers.</p><p><strong>Methods: </strong>We present findings from prespecified and post hoc analyses from the TRAILBLAZER-ALZ 2 trial. Clinical outcomes assessed were Integrated AD Rating Scale (iADRS), comprising the 13-item AD Assessment Scale-Cognitive Subscale (ADAS-Cog₁₃) and AD Cooperative Study-Instrumental Activities of Daily Living (ADCS-iADL); Clinical Dementia Rating (CDR)-Sum of Boxes (CDR-SB) for clinical severity and individual cognitive and functional domains; CDR-Global for clinical severity stage progression; meaningful within-patient change (MWPC); and ADCS-Activities of Daily Living dependence score.</p><p><strong>Results: </strong>Donanemab reduced the risk of progression from MCI to mild AD by 33% (hazard ratio [HR] = 0.67; 95% CI 0.52-0.87; <i>p</i> = 0.003) and from mild to moderate AD by 50% (HR = 0.50; 95% CI 0.33-0.78; <i>p</i> = 0.002). In addition, donanemab reduced MWPC risk over 76 weeks by 38% for CDR-SB (HR = 0.62; 95% CI 0.52-0.75; <i>p</i> < 0.001) and 30% for iADRS (HR = 0.70; 95% CI 0.58-0.84; <i>p</i> < 0.001). Donanemab-treated participants exhibited significant slowing of clinical progression across multiple ADAS-Cog₁₃ and ADCS-iADL items and all CDR-SB cognitive and functional domains. Donanemab also slowed progression of dependence least-squares mean change difference, -0.14 [95% CI -0.24 to -0.04; <i>p</i> = 0.007]), representing 23% slowing of progression (95% CI 6.17%-40.32%), and reduced risk of progression to requiring in-home support by 27% (HR = 0.74; 95% CI 0.59-0.91; <i>p</i> = 0.005).</p><p><strong>Discussion: </strong>These results add to the evidence and further support clinically meaningful donanemab-mediated effects on cognition and function for patients and their caregivers and may aid communication of realistic treatment expectations and informed decision-making.</p><p><strong>Trial registration information: </strong>ClinicalTrials.gov NCT04437511. Submitted: June 17, 2020; First patient enrolled: June 19, 2020. clinicaltrials.gov/study/NCT04437511 EudraCT Number 2020-000077-25. Start date of recruitment: June 19, 2020. clinicaltrialsregister.eu/ctr-search/trial/2020-000077-25/results.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200621"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13178146/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147932033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of Swallowing in Poststroke Individuals Using the Swallowing Proficiency for Eating and Drinking (SPEAD) Protocol: A Pilot Study.","authors":"Uzair Chilwan, Aswathy Suresh, Sahlah Shameer, Anaan Zohara, Radish Kumar Balasubramanium","doi":"10.1212/CPJ.0000000000200625","DOIUrl":"10.1212/CPJ.0000000000200625","url":null,"abstract":"<p><strong>Background and objectives: </strong>Poststroke dysphagia affects 37-78% of stroke survivors, leading to complications such as malnutrition, dehydration, and psychological distress. Current tools for assessing swallowing, such as the Timed Water Swallow Test and Test of Mastication and Swallowing Solids, do not evaluate intermediate consistencies. The Swallowing Proficiency for Eating and Drinking (SPEAD) protocol incorporates thin liquids, solids, and moderately thick liquids, providing a comprehensive evaluation of swallowing function. This study assessed SPEAD's utility in a stroke population and its relationship with stroke severity.</p><p><strong>Methods: </strong>A cross-sectional study recruited 77 poststroke participants (aged ≥18 years). Swallowing was evaluated using SPEAD for thin liquids, moderately thick liquids, and solids, following International Dysphagia Diet Standardization Initiative guidelines. Parameters recorded included number of swallows, chews, grams consumed, and duration (in seconds), with derived measures such as ingestion speed and SPEAD rate. Stroke severity was assessed using the NIH Stroke Scale, and self-reported swallowing difficulties were screened with Eating assessment Tool (EAT-10). Data were analyzed using analysis of variance (ANOVA), multivariate analysis of variance, and Pearson correlation.</p><p><strong>Results: </strong>Participants with moderately severe strokes demonstrated slower ingestion speeds and increased effort across all consistencies. Significant differences were observed in SPEAD parameters between consistencies, with solids requiring higher ingestion times and effort. Stroke severity correlated moderately with SPEAD measures (<i>r</i> = -0.45 to -0.62, <i>p</i> < 0.05). A significant correlation was observed between SPEAD and EAT-10 scores, indicating that participants with higher dysphagia burden as perceived through SPEAD also reported greater perceived difficulty with swallowing on EAT-10.</p><p><strong>Discussion: </strong>The SPEAD protocol effectively identifies swallowing impairments in stroke patients, particularly for intermediate consistencies. Its comprehensive approach provides valuable insights for dysphagia management, emphasizing the need for further validation in diverse populations. The study also highlights the value of objective bedside assessments such as SPEAD in conjunction with patient reported outcomes such as EAT-10. Together, they offer a comprehensive understanding of swallowing function poststroke and can guide early intervention strategies.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200625"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13155697/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147874275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Addressing Barriers to Transitioning Pediatric Patients With Epilepsy to Adult Health Care in the United States: A Narrative Review.","authors":"M Scott Perry, Fábio A Nascimento, Jesus E Pina-Garza, Michael G Chez, José A Ferreira, Adrian L Rabinowicz, Enrique Carrazana","doi":"10.1212/CPJ.0000000000200616","DOIUrl":"10.1212/CPJ.0000000000200616","url":null,"abstract":"<p><strong>Purpose of review: </strong>Adolescents with childhood-onset epilepsy, along with their families, must navigate a complex constellation of uncertainties related to physical, psychological, and social changes as well as medical and possibly legal ramifications as they approach adulthood. Transferring from the familiar pediatric setting to the adult health care system can be a time of concern because of actual and/or perceived differences between the settings (e.g., uncertainty about the patient entering a completely new system, providers focused on adults rather than children, patient behavior in a new environment, and less parental involvement). These concerns can be eased by a focused transition program, with clinicians providing a guiding hand for a smooth transfer into adult health care.</p><p><strong>Recent findings: </strong>Models of transition processes involving epilepsy education, assessment of readiness for transfer, and validation of patient preparedness for self-management, when possible, are available in toolkits and publications. These resources address the need for focused transition care for patients with epilepsy; however, practical suggestions that clearly discuss barriers to transition in the US fee-for-service health care system, and strategies for addressing those barriers, are lacking.</p><p><strong>Summary: </strong>In this study, we discuss features of transition programs for patients with epilepsy outside the United States and for patients in the United States with other disease conditions. We then detail the barriers to transition for patients with epilepsy in the United States, compiling them into categories with tables for quick and clear access. Along with the barriers, we provide clinicians treating adolescent patients with epilepsy with resources from which they can select the appropriate features best suited for addressing their institution's needs as well as the needs of patients, including those with complex epilepsies, such as developmental and epileptic encephalopathies.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200616"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13155695/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147875217","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Approach to Postural Orthostatic Tachycardia Syndrome.","authors":"Nathaniel M Robbins, Elisabeth P Golden, Kelly C Freeman, Ratna K Bhavaraju-Sanka, Howard Snapper, Glen A Cook","doi":"10.1212/CPJ.0000000000200620","DOIUrl":"10.1212/CPJ.0000000000200620","url":null,"abstract":"<p><strong>Purpose of review: </strong>To support general neurologists, advanced practice providers, and general practitioners in the diagnosis and treatment of postural tachycardia syndrome (POTS) and related dysautonomias. This review and approach are based on the authors' clinical experience, nonsystematic literature review, and expert opinion, with experts drawn from the American Autonomic Society Education Committee.</p><p><strong>Recent findings: </strong>POTS is a common condition seen in general practice. The diagnosis can be easily made in a nonspecialist setting when patients meet the syndromic criteria for POTS: (1) chronic orthostatic intolerance (bothersome symptoms brought on by upright posture, and relieved by lying down), (2) excessive orthostatic tachycardia (heart rate augmentation with standing greater than 30 beats per minute in adults), (3) absence of orthostatic hypotension, and (4) reasonable exclusion of other causes (e.g., dehydration, anemia, hyperthyroidism). There are many causes, but the unifying perturbations are low effective circulating volume with decreased cerebral blood flow and a hypersympathetic state. Education and nonpharmacologic therapies such as salt, water, and exercise are first-line treatments. Several safe and effective medication options are also available, such as propranolol and midodrine. Several comorbidities are common, such as migraine and neurocardiogenic syncope, and should be screened for and treated rather than attributed out-of-hand to POTS.</p><p><strong>Summary: </strong>POTS and related conditions are common. Initial diagnostic and treatment steps can be undertaken in a general practice setting. Referral to specialists is appropriate for refractory cases or when the diagnosis is uncertain.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200620"},"PeriodicalIF":3.2,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13155696/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147875189","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinician Communication About Uncertainty During Parkinson Disease Diagnostic Consultations.","authors":"Marij A Hillen, Elisabeth Kurpershoek, Mark H B Huisman, C Machiel Pleizier, Annemarie Vlaar, Jeroen Blankevoort, Evelien Zoons, Dareia S Roos, Marianne de Visser, Rob M A de Bie, Joke M Dijk","doi":"10.1212/CPJ.0000000000200613","DOIUrl":"10.1212/CPJ.0000000000200613","url":null,"abstract":"<p><strong>Background and objectives: </strong>Parkinson disease (PD) entails much uncertainty, regarding diagnosis, disease course, and treatment. How clinicians communicate about such uncertainty may affect patients' understanding of the information and their well-being. However, clinicians rarely receive formal training in how to optimally discuss uncertainty during diagnostic consultations. We assessed (1) how clinicians communicate about uncertainty, (2) how their communication about uncertainty predicts patients' feelings of uncertainty and trust, and (3) the moderating effect of clinicians' and patients' tolerance for uncertainty.</p><p><strong>Methods: </strong>We recorded diagnostic consultations regarding PD (initial and follow-up within 6 weeks) for 50 patients. The frequencies of clinicians' verbal expressions of uncertainty were systematically coded for topic, initiative, explicitness, and communication approach. Moreover, clinicians' reactions on patients' and companions' uncertainty expressions were coded. Patients and clinicians completed multiple surveys assessing background characteristics, uncertainty tolerance, feelings of uncertainty, and trust. We conducted descriptive analyses and fitted mixed linear models.</p><p><strong>Results: </strong>Clinicians expressed uncertainty on average 20 times over both diagnostic consultations combined (range 6-67; 0.40 p/min). Most statements concerned medication (31%) and diagnosis (30%), and uncertainty was predominately conveyed implicitly (mean = 74%). The most frequently observed communication approach (30%) was outlining a plan to obtain more certainty. Patients or companions expressed uncertainty on average 12 times (range 1-29; 0.20 p/min), to which clinicians most often responded by providing more information (67%). Patients' feelings of uncertainty decreased after the diagnostic consultation(s). Clinicians' uncertainty tolerance was not associated with their uncertainty communication. Neither patients' nor clinicians' uncertainty tolerance moderated the association between uncertainty communication and patient-reported outcomes.</p><p><strong>Discussion: </strong>Uncertainty is integral to PD diagnostic consultations and does not seem to have harmful effects on patient well-being. Its discussion often remains implicit and is strongly focused on justifying or reducing the uncertainty. More systematic research could assess the effects of various ways to convey uncertainty on patients' well-being and trust.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"16 3","pages":"e200613"},"PeriodicalIF":3.7,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13156960/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147875285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}