Artificial intelligence (AI) applications in neurology have reached an inflection point. Despite US Food and Drug Administration approval of numerous algorithms in neuroimaging, neurophysiology, genetics and chatbots, their real-world impact remains limited. This disconnect between research promise and clinical reality represents a gap in understanding how to translate AI algorithms into clinical benefit for patients globally. In this Perspective, we examine the challenges that prevent clinical AI use in neurology moving beyond pilot studies towards meaningful clinical impact. We consider the steps required in the process of translation, including research, validation of AI models, regulatory approval pathways and clinical implementation. We discuss implementation of AI models as stand-alone products versus embedded platforms, and the requirements for sustainable deployment. Beyond traditional clinical decision support tools, we examine paraclinical applications of AI, including chatbots and ambient voice documentation. We recommend expanding capacity for prospective validation and scaling by implementing and validating technologies across multiple sites and countries, which requires infrastructure from long-term partnerships. Neurology must shift from asking whether AI can work to understanding how to use it safely at scale.
BACKGROUND: The application of chaos theory has positive results in different fields of science. Its nonlinear modeling properties and its vision of dynamic systems have enabled it to capture complex relationships in fields such as physics, financial econometrics, social systems and mathematical demography. This paper reviews the implication of chaos theory in the medical sciences. METHODOLOGY: We carried out a systematic literature review under Cochrane’s international standards. A search strategy was executed with indexed terms (MeSH, DeCS and Emtree) that varied according to each database (Embase, MEDLINE, SciELO, LILACS). The PROSPERO registration number was CRD42023491407. FINDINGS: In total, 2598 articles were retrieved, of which 20 were included. Algorithmic applications of chaotic systems were diverse. The medical fields with the largest studies were cardiology, neurology and oncology. The most used software was Matlab, however, in all cases, except one, we did not find open-source codes related to the studies. INTERPRETATION: We found a wide heterogeneity in the studies reviewed, and this was reflected in the scope of research results. While some papers focus on proving the existence of chaotic behavior or understanding the nature of the phenomena being studied, others propose practical implications, such as in prescribing medicines and organizing health units. CLINICAL TRIAL NUMBER: Not applicable.
The so-called Someya's sinew string is a linear structure observed in the buccal mucosa distal to the mandibular second molar and is primarily recognized in Japanese prosthodontic practice. Although previous studies have described its prevalence and clinical importance, particularly during impression procedures for removable prostheses, its anatomical basis remains unclear, and it is not formally defined in standard anatomical terminology. This study reviews the existing literature and reexamines the nature of this structure from anatomical and surgical perspectives. Based on clinical observations and previously reported findings, we propose that Someya's sinew string may represent postoperative scar tissue following mandibular third molar extraction rather than a distinct anatomical entity. Its location, linear morphology, low prevalence, and frequent asymmetry support this interpretation. Additionally, none of the cases observed in our experience exhibited intact mandibular third molars. Although this hypothesis remains unverified, it provides a coherent explanation consistent with current clinical and structural observations. Importantly, regardless of its origin, this structure remains clinically relevant and should be recognized in prosthodontic practice, particularly during impression procedures. Further studies, including histological and imaging analyses, are warranted to clarify its biological nature.
All physicians will experience challenging history taking encounters, where communication is impaired and negatively impacts the diagnostic process. The aims of this systematic review were to (1) undertake a meta-analysis of the frequency of challenging encounters; (2) collate adverse outcomes of challenging encounters; (3) identify underlying causes of challenging encounters; (4) identify strategies to deal with different challenges; and (5) align these strategies with our published phenomenological framework of history taking challenges. This was a systematic review and meta-analysis of prevalence data adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses and the Meta-analyses of Observational Studies in Epidemiology guidelines. A literature search in MEDLINE, Embase and Cochrane databases was performed on 12 July 2020, and updated on 4 August 2025, focusing on challenging history taking encounters in any clinical setting. Articles reporting on the frequency, adverse outcomes, causative factors or strategies used to address challenges in the history taking process in any clinical area of medicine. Factors associated with challenging history encounters (causative or consequential) were categorised using inductive coding and referenced to a phenomenological framework. Meta-analysis was used to estimate the prevalence of history taking encounters using a restricted maximum likelihood model with τ 2 and I 2 as tests for heterogeneity and funnel plot with Egger's test for publication bias. 73 articles were included in the analysis. The overall prevalence of challenging history taking encounters was 19.5% (95% CI 14.2% to 24.7%). Adverse outcomes of patient dissatisfaction (level 1 evidence) and diagnostic uncertainty (level 3 evidence) were identified. Factors associated with (n=22) and strategies to mitigate challenging encounters (n=13) were categorised. Correlation of factors and strategies with a phenomenological approach created a framework to assist novice history takers in approaching such circumstances. Challenging history taking encounters are common. Little is known of the relative importance of factors associated with challenging history taking encounters or the impact of suggested strategies. Many of the suggested strategies to facilitate meaningful communication in these situations involve a departure from standard history taking. More research is required to better define the nature of challenges encountered in history taking with a view to develop better educational models for trainee physicians.
This scoping review aims to identify, map, and synthesize evidence on the sexual and reproductive health (SRH) information needs of youth 15-24 years living with epilepsy, congenital heart disease (CHD), or systemic lupus erythematosus (SLE) in the USA and Canada, and identify barriers and facilitators to access to SRH information and services. Youth and young adults with chronic health conditions face elevated and condition-specific reproductive risks. Among youth with epilepsy, interactions between seizures, antiseizure medications, hormones, and hormonal contraceptives increase the risk of unintended pregnancy. For youth with congenital heart disease, a substantial proportion of pregnancies are associated with cardiac complications, and contraceptive counseling is often delayed or inconsistently delivered. In systemic lupus erythematosus, limited contraceptive options and teratogenic therapies further heighten reproductive risk, with active disease associated with significantly increased risks of preterm birth and pre-eclampsia. Despite these well-documented risks, youth with chronic conditions frequently report unmet SRH information needs related to contraception, medication safety, fertility, and pregnancy planning. Evidence remains fragmented across specialties and largely focused on pregnancy outcomes rather than youth-centered informational needs and access to services. Our preliminary search did not identify a comprehensive scoping review that maps sexual and reproductive health (SRH) information needs, barriers, and facilitators across these three chronic conditions among young people in North America. Given the anticipated heterogeneity in study designs, populations, and outcomes, a scoping review is appropriate for characterizing the breadth and nature of the evidence base. Eligible sources will include empirical studies from the USA and Canada involving youth aged 15-24 years diagnosed with epilepsy, CHD, or SLE. Studies must address SRH information needs and/or barriers and facilitators to accessing SRH information or services. Youth-reported needs will be distinguished from caregiver or provider perspectives, which will be included only when directly relevant to youth experiences. All primary qualitative, quantitative, and mixed-methods designs, as well as empirical grey literature, will be considered. This review will follow Joanna Briggs Institute (JBI) methodology for scoping reviews and will be reported in accordance with the PRISMA-ScR guidelines. A three-step search strategy will be implemented across MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, CENTRAL, and targeted grey literature sources from the inception of each database to the final search date. Two reviewers will independently screen records and extract data using a piloted standardized tool. Results will be synthesized descriptively and analyzed using manifest-level content analysis to categorize SRH information needs, barriers, and facilitators. Findings will be mapped across socio-ecological levels and developmental stages (15-19 and 20-24 years), where data permit. This protocol is registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/5SWTY).
Migraine is a chronic neurological disorder and a leading cause of disability worldwide. In India, it poses a significant public health challenge, with prevalence estimates ranging from 14% to 28.7%. The objective of the work was to assess the epidemiological burden of migraine in India and critically examine clinical, social, and infrastructural challenges impacting its management and policy support. A narrative review of peer-reviewed literature published between 2015 and 2025 was conducted using PubMed, Scopus, and Web of Science, focusing on migraine diagnosis, treatment advances, and policy frameworks. Searches included terms such as "early diagnosis," "medication overuse headache," "policy support," and "novel migraine therapies," prioritizing systematic reviews and meta-analyses. Expert insights were also incorporated through thematic analysis of discussions from a dedicated migraine session at the 69 th Annual National Conference of the Indian Public Health Association (March 2025, Belagavi). The results demonstrate that migraine affects over 213 million individuals in India, disproportionately impacting women and working-age populations. Current therapeutic approaches lack personalization, and access to innovative treatments remains limited due to regulatory and insurance gaps. Policy neglect and sociocultural stigma exacerbate disease burden. This report highlights the debilitating nature of Migraine and the associated economic loss in India, which remains under-recognized in policy and insurance frameworks. A multidisciplinary, patient-centered approach integrating clinical innovation, policy reform, and mental health support is found to be the need of the hour.
Monoclonal antibodies (mAbs) targeting the Calcitonin Gene-Related Peptide (CGRP) pathway are safe and effective treatments for migraine prevention. However, the high cost of these novel therapies has led to reimbursement policies requiring patients to try multiple traditional preventives before access. Here, we evaluate the real-world effectiveness of onabotulinumtoxinA (BoNT-A) as first-line treatment and describe the sequential transition to anti-CGRP monoclonal antibodies in patients who did not achieve sufficient response, within the Polish chronic migraine treatment program. In this retrospective cohort study, we included 94 patients with chronic migraine who received BoNT-A treatment according to the PREEMPT protocol every 3-4 months for 12 months as first-line treatment. Headache diaries and documentation were used to evaluate reductions in monthly headache days (MHD) and MIDAS scores. Patients were divided into two subgroups based on their response after three BoNT-A administrations: insufficient response (≤ 50% reduction in MHD) and sufficient response (> 50% reduction in MHD). We included 94 patients (93.62% female, age range 22-66 years). Following three BoNT-A injection cycles, 70 patients (74.47%) did not achieve the ≥ 50% response threshold and were sequentially transitioned to fremanezumab per programme protocol. In the insufficient response group, MHD decreased from 18.26 ± 4.46 to 13.90 ± 4.64 days (t(69) = 15.49, p < 0.001), representing a 23.9% reduction, while MIDAS scores decreased from 93.77 ± 41.80 to 61.69 ± 35.56 (t(69) = 10.22, p < 0.001, 34.2% reduction). In the sufficient response group (n = 24, 25.53%), MHD decreased from 17.83 ± 1.95 to 7.83 ± 1.83 days after 3 injections (56.1% reduction, t(23) = 31.97, p < 0.001), and further to 4.13 ± 1.77 days after 5 injections (76.7% reduction, t(22) = 32.59, p < 0.001). Pearson's correlation analysis revealed moderate positive correlation between MHD and MIDAS after 3 injections (r = 0.392, p < 0.001), which weakened substantially after 5 injections (r = 0.082, p = 0.691). Baseline MIDAS scores were numerically higher in the sufficient response group (116.62 ± 61.12 vs. 93.77 ± 41.80, t(92) = 2.04, p = 0.044); however, given the outcome-dependent nature of group allocation, this difference should not be interpreted causally or as a prognostic marker. For patients who did not experience sufficient improvement after the third BoNT-A administration, treatment was changed to fremanezumab. Our real-world data demonstrate that 74.47% of patients with chronic migraine did not achieve the ≥ 50% MHD reduction threshold after three onabotulinumtoxinA injections, supporting the current Polish therapeutic algorithm that allows sequential transition to anti-CGRP monoclonal antibodies for insufficient responders.
Pain is a critical yet frequently underestimated component in the care of patients with acquired brain injury (ABI) and disorders of consciousness (DoC). Because these individuals often lack the ability to communicate verbally or purposefully, clinicians face substantial challenges in recognizing and managing pain, despite its profound influence on autonomic stability, behavioural responsiveness, rehabilitation engagement and overall prognosis. This position paper synthesizes current knowledge on the multidimensional nature of pain and reviews the main behavioural, autonomic and neurophysiological tools available to assess nociception and pain-related processing in non-communicative patients. By integrating evidence from standard clinical scales with advanced physiological markers and neuroimaging findings, we highlight how preserved activity within the so-called pain matrix challenges traditional assumptions about pain absence in DoC populations. The paper argues for a shift toward multimodal, patient-centred approaches that combine behavioural observation with objective physiological indicators to improve diagnostic accuracy and ensure ethically responsible care. Practical guidance is provided on selecting appropriate assessment tools, interpreting behavioural and physiological signs of nociception, and implementing more effective pain management strategies. Accurate pain assessment is essential not only to promote recovery and facilitate rehabilitation but also to uphold the central ethical principle of safeguarding the dignity of patients with disorders of consciousness. Understanding pain in Disorders of Consciousness (DoC) is a major clinical and ethical challenge, as residual nociceptive processing may be underestimated. This study advances a multidimensional framework integrating behavioural and neurophysiological evidence, moving beyond simple detection toward interpretation of pain meaning. It has direct implications for improving pain assessment, guiding personalized management and supporting more accurate and ethically grounded care in non-communicative patients.
Sharing serious information (SSI) is a critical communication skill for physicians. Existing frameworks vary in their teaching and application, and many physicians desire better training. This study aimed to develop a theory-informed framework and cognitive aid for sharing serious information (SSI) through a multiphased development process involving a systematic review and expert focus groups. A multiphased approach was used: (1) a systematic review of four databases (1983-2024) to identify core components of SSI; and (2) twelve multidisciplinary focus groups (2022-2024) using the nominal group technique to integrate these components into a structured framework. A modified PICO/PEO approach (Population, Exposure/Intervention, Outcomes) guided study selection, and the AMSTAR2 tool was only used for quality appraisal of systematic reviews. From 4,892 titles/abstracts, 52 were selected for inclusion. Thematic synthesis identified eight themes for optimal SSI: (1) limiting delay between diagnosis and SSI, (2) preparation time for meetings, (3) patient-centered communication, (4) discussion of emotions, (5) verifying understanding, (6) affirmation of treatment options, (7) offering a confidant, and (8) providing information resources. These themes, interpreted cautiously across heterogeneous evidence sources, informed the development of the MEET & MAKE CleaR PROCESS framework, encompassing preparation (MEET), sharing (MAKE), clarification (CleaR), and ongoing plan (PROCESS). The MEET & MAKE CleaR PROCESS framework and its cognitive aid aim to equip educators and clinicians with a structured approach to instructing and managing SSI encounters especially with simulation-based education. We believe this up-to-date framework could minimize the negative impact of SSI on patients, relatives, and physicians.
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UK Biobank is the world's most comprehensive longitudinal population-based data and biosample resource. Twenty years after UK Biobank was first established, the incidence of dementia among participants is rising and is set to increase rapidly over the next 5-10 years, creating a distinct opportunity for studies of dementia risk and onset. In addition to extensive clinical phenotyping of >500,000 volunteers from across the UK at recruitment and at follow-up time points, UK Biobank includes data from serial lifestyle questionnaires, cognitive testing, multimodal imaging, accelerometry, genomics and other omics that are linked to individual health, cancer and death records. In this Perspective, we discuss how the use of UK Biobank data has enabled the discovery of new interactions between systemic and brain health and illustrate how these data can be used to characterize and identify risk factors, support mechanistic hypotheses and identify new biomarkers that predict the onset and course of dementia and related disorders. We also consider future developments of UK Biobank, including the UK Biobank Brain Health Study, which will build on and leverage the increasing incidence of dementias to advance understanding of these conditions.
Post-COVID-19 condition (PCC), also known as long COVID, is a heterogeneous condition marked by persistent symptoms following acute SARS-CoV-2 infection. As approximately 6% of people who have experienced acute COVID-19 are estimated to develop PCC, the potential population is vast. Many of the key symptoms of PCC reflect involvement of the nervous system, ranging from cognitive impairment ('brain fog'), headaches and fatigue to anxiety and depression. This Review summarizes the spectrum of neurological and psychological symptoms that occur following acute SARS-CoV-2 infection, with a particular focus on the international consensus-based core outcome set for PCC. We also explore the proposed underlying mechanisms, including evidence for immune system dysregulation, microvascular dysfunction and volumetric changes on neuroimaging. In addition, we review ongoing and completed large-scale treatment trials. Growing evidence suggests a bidirectional interaction between symptoms traditionally considered neurobiological in origin, such as cognitive deficits and headache, and those within the purview of psychiatry, such as anxiety and depression. PCC represents an opportunity to better understand the long-term consequences of acute infection and improve management strategies and outcomes, not only for people with the condition but also for those with other post-viral syndromes that affect brain health.
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Multiple sclerosis (MS) is a condition marked by considerable prognostic uncertainty, despite advances in therapeutic strategies and biomarker development. Current approaches to prognosis are largely focused on disease burden, failing to consider the influence of compensatory mechanisms, which complicate the evaluation of long-term outcomes. No unified framework currently exists to guide the integration of diverse prognostic factors, ranging from lesion burden and location to neuroaxonal injury, structural and cognitive reserve, lifestyle and digital biomarkers. To address this gap, a consortium from the Magnetic Resonance Imaging in MS (MAGNIMS) network has reviewed the latest research on MS prognosis and, in this Expert Recommendation, proposes a multiaxial conceptual model that incorporates the overall burden of damage, the topography of injury and the capacity for compensation. These three axes can be explored with different tools, such as clinical history and neurological examination, MRI-based tools, biofluid markers and additional techniques, including multimodal evoked potentials, optical coherence tomography and technology-based passive monitoring systems. The MAGNIMS consortium evaluated the existing tools, their limitations and potential future directions across each axis, proposing an integrated, non-prescriptive framework for individualized risk prediction. This work is intended not as a clinical guideline but as a conceptual roadmap to inform future research and refinement of prognostic models in MS.