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Research Letter
March 3, 2025
Brian C.Callaghan,MD, MS1; Evan L.Reynolds,PhD2; LavanyaMuthukumar,MS1; et al Melissa A.Elafros,MD, PhD1; Lesli E.Skolarus,MD, MS3; James F.Burke,MD, MS4; Kevin A.Kerber,MD, MS4
Author Affiliations Article Information
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1Department of Neurology, University of Michigan, Ann Arbor
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2Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
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3Department of Neurology, Northwestern University, Chicago, Illinois
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4Department of Neurology, Ohio State University, Columbus
JAMA Neurol. 2025;82(4):420-421. doi:10.1001/jamaneurol.2025.0001
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American Academy of Neurology (AAN) guidelines recommend diagnostic testing for fasting glucose, vitamin B12, and serum protein electrophoresis (SPEP) in patients with peripheral neuropathy (PN) and a glucose tolerance test (GTT) in those without diabetes on routine testing.1 Magnetic resonance imaging (MRIs) of the brain and spinal cord and electrodiagnostic testing (EMG) are frequently ordered and drive most of the diagnostic costs but rarely change diagnosis or management.2 Current guidelines3,4 recommend against using MRIs for evaluation of PN and performing routine EMG for diabetic neuropathy. Using Medicare data from 1998 to 2007, we found that AAN guideline–recommended tests, particularly SPEP and GTT, were likely underused and MRIs and EMGs were likely overused.5 However, whether use has changed after publication of current recommendations3,4 remains unknown.
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April 3, 2025
Bridging the Knowledge Gap in Peripheral Neuropathy Diagnosis: The Impact of Specialty-Driven Cognitive Bias on Guideline Adherence
游绍华, MD degree | Department of Pain Medicine, The First Medical Center of Chinese PLA General Hospital
The recent article by Dr. Brian C. Callaghan et al in JAMA Neurology has drawn our attention. Specialty - driven cognitive bias may affect guideline adherence in diagnosing peripheral neuropathy (PN). Patients with PN usually first visit neurology, orthopedics, pain medicine, or rehabilitation departments. Physicians in these departments are more familiar with tests like fasting glucose, HbA1c, electromyography (EMG), and MRI than glucose tolerance testing (GTT) and serum protein electrophoresis (SPEP). This shows a contradiction between “knowledge inertia” and “guideline recommendations” in the specialized medical system. Neurologists, orthopedic surgeons, and pain specialists prefer familiar diagnostic tools. EMG and MRI are favored for direct nerve - damage localization, and fasting glucose and HbA1c are used for diabetes screening. However, GTT and SPEP are significantly underutilized, with usage rates of 1.0% and 13.4% respectively. The underuse is due to GTT's procedural complexity and SPEP's interpretative challenges, as well as the need for referrals in fragmented care systems. Despite guidelines advocating GTT and SPEP, EMG and MRI utilization rates remain high, while GTT and SPEP rates are low. This may lead to missed diagnoses of reversible causes of PN. The root causes lie in specialized training and clinical pathways. Neurology training emphasizes EMG and MRI, overlooking metabolic evaluations; orthopedics and pain medicine training focus on structural lesions, lacking knowledge of hematological diseases. Operational challenges also contribute to underuse.
To address these issues, several strategies can be adopted. Educational interventions across specialties can emphasize SPEP interpretation and GTT indications. Clinical decision support tools can embed guidelines into electronic health records. System - level optimizations, such as streamlined testing pathways and rapid consultation networks, can facilitate test ordering and interpretation. Behavioral nudges can promote guideline - concordant practice.
In conclusion, systemic interventions are essential to bridge the gap between familiarity and guidelines, and transform GTT and SPEP into routine tools for patient - centered, etiology - oriented diagnosis and treatment of PN.
CONFLICT OF INTEREST: None Reported
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Neurology Neuromuscular Diseases Neuropathy
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Callaghan BC, Reynolds EL, Muthukumar L, et al. Diagnostic Testing for Patients With Peripheral Neuropathy. JAMA Neurol. 2025;82(4):420–421. doi:10.1001/jamaneurol.2025.0001
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