Welcome to Med Op-Ed, where we highlight recently published editorials in neurology. In this installment: the reality behind the “Parkinson pandemic”; fighting administrative bloat in neurology; and consensus on patient selection in left atrial appendage closure (LAAC) — maybe.

Are More People Developing Parkinson’s Disease (PD), or Just Living With It?

While the absolute number of people living with PD continues to rise globally, population-based studies do not support a consistent increase in age-adjusted disease risk, with many studies in high-income settings showing stable or declining incidence rates after accounting for demographic aging. This distinction adds context to the “Parkinson pandemic” narrative and suggests that the growing disease burden is largely driven by population aging, longer survival, and improved diagnostic ascertainment rather than a clear increase in underlying risk, according to a Viewpoint article in Movement Disorders written by Daniele Urso, MD, MPH; Yoav Ben-Shlomo, MD, PhD; Giancarlo Logroscino, MD, PhD; and Anette Schrag, MD, PhD.

The Context

• Prevalence is the net result of new cases and deaths, so it depends on incidence, disease duration, survival, diagnostic ascertainment, and population age structure. The number of people with PD can therefore rise even when age-specific risk remains stable or decreases. The authors pointed to dementia as a similar case but added that it is uncertain whether the same mechanism applies to PD.
• A narrative review of population-based studies in North America, Europe, and Asia found that most reported declines in age-adjusted incidence, while others reported stable trends. Only two studies — from the US and Taiwan — reported increases. The authors cautioned that reliable incidence data are scarce in low- and middle-income countries, where about 85% of the world’s population lives.
• The authors said the findings do not undercut the case for prevention. They support the search for modifiable risk factors and a goal, recently proposed by other researchers, of no increase in global PD incidence by 2035. Some settings may already be close to meeting that goal, but confirming it will take better measurement, they added.

In Their Own Words

“Importantly, this conclusion does not weaken the case for prevention. On the contrary, it supports the drive to identify and reduce modifiable risk factors and addresses the first goal recently proposed in the ‘PLAN’ to address the Parkinson pandemic: a 0% increase in the global incidence of PD by 2035.”

Read it: The Worldwide Burden of Parkinson’s Disease Is Growing, but Its Incidence Is Not: Lessons From Population-Based Studies

Is Your Neurology Department Drowning in Administrative Bloat?

Academic medicine’s tendency to create new administrative processes in response to nearly every problem has generated a growing bureaucratic burden that consumes clinician and researcher time, wrote S. Thomas Carmichael, MD, PhD, of the David Geffen School of Medicine at the University of California, Los Angeles, in a Viewpoint article in JAMA Neurology. Departments should ask five questions before adopting any new process, Carmichael noted, and prune obsolete ones.

The Context

• A conceptual model of administrative bloat developed by other researchers suggests that a high “creation propensity” — the tendency to create new processes in response to nearly every problem — and no systematic effort to phase out old ones can create a cycle in which accumulated processes consume the time needed to decide which ones to retire.
• Before adopting any new administrative process, Carmichael said that departments should ask five questions: What problem is it solving? Is it serious and frequent enough to warrant an ongoing process? Who will bear the full cost, including clinician and investigator time? When will it be reviewed, and by whom? And what will be stopped to make room for it? Not every problem needs an ongoing process, Carmichael added, and the last question may be the most important.
• In the 2018 Federal Demonstration Partnership survey, 11,167 principal investigators estimated that 44.3% of federally funded research time went to administrative requirements instead of research itself; 62% said they believed the administrative workload significantly compromised their productivity. Nearly one third (31%) said it discouraged federal grant submission.

In Their Own Words

“A code stroke checklist is not bloat. An antiamyloid infusion protocol is not bureaucratic excess. But not every problem is an airplane maintenance problem. Some are light bulb problems. When the light bulb burns out, we replace it. We do not need a Light Bulb Failure Prevention Committee, an annual attestation module, and an assistant vice dean for illumination resilience.”

Read it: Administrative Bloat in Neurology and Academic Medicine

Who Is LAAC Really for?

LAAC should be a choice mainly for patients willing to accept a modestly higher risk for ischemic stroke or procedural complications in exchange for freedom from long-term medication, rather than serving as a default alternative to direct oral anticoagulants (DOACs) for atrial fibrillation-related stroke prevention, wrote David Seiffge, MD, of Inselspital University Hospital and the University of Bern in Bern, Switzerland, and colleagues in a Viewpoint article in JAMA Neurology. Their commentary on two recent trials, CLOSURE-AF and CHAMPION-AF, concluded that although the procedure appears to accomplish its biological goal of preventing stroke, its overall risk-benefit profile is less favorable than that of DOACs.

The Context

• CLOSURE-AF, which enrolled 912 patients at high risk for both stroke and bleeding, did not show LAAC to be noninferior to medical therapy, largely because of a 2% absolute higher rate of death with LAAC. CHAMPION-AF, which randomly assigned 3000 lower-risk patients, met its noninferiority margin, but ischemic stroke was more common with LAAC than with DOACs (3.2% vs 2.0%).
• The authors said the patients most at risk for bleeding on anticoagulants are not automatically the best candidates for LAAC because the same features — age, frailty, kidney dysfunction, previous bleeding, and multimorbidity — also raise the risk for stroke from other sources and for bleeding from the procedure. Hemorrhagic stroke rates did not differ between LAAC and medical therapy in either trial, which the authors said appears to weaken LAAC's presumed advantage.
• The authors said LAAC may still be a reasonable option for patients who cannot take long-term anticoagulation, such as those with lobar hemorrhage or cerebral amyloid angiopathy, though its benefit has not been proven. These patients were not included in either trial, and intracerebral bleeding did not differ between the LAAC and medical therapy groups in either one. The authors said the benefit in this group is a possibility that still needs to be tested. Ongoing trials, including STROKE-CLOSE, ASAP-TOO, CLEARANCE, and A3ICH, are enrolling this group.

In Their Own Words

“How should physicians now consider LAAC for their patients? Neither trial specifically studies patients after stroke who face higher risks. Extrapolation is therefore limited. Still, the findings argue against LAAC as a default alternative to long-term DOAC therapy for AF-related stroke prevention.”

Read it: Left Atrial Appendage Occlusion — Is the Case Now Closed?

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.