Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.

OBJECTIVE: To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). METHODS: The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include breaking the news, multidisciplinary clinics, symptom management, cognitive and behavioral impairment, communication, and palliative care for patients with ALS. RESULTS: The authors identified 2 Class I studies, 8 Class II studies, and 30 Class III studies in ALS, but many important areas have been little studied. More high-quality, controlled studies of symptomatic therapies and palliative care are needed to guide management and assess outcomes in patients with ALS. RECOMMENDATIONS: Multidisciplinary clinic referral should be considered for managing patients with ALS to optimize health care delivery and prolong survival (Level B) and may be considered to enhance quality of life (Level C). For the treatment of refractory sialorrhea, botulinum toxin B should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C). For treatment of pseudobulbar affect, dextromethorphan and quinidine should be considered if approved by the US Food and Drug Administration (Level B). For patients who develop fatigue while taking riluzole, withholding the drug may be considered (Level C). Because many patients with ALS demonstrate cognitive impairment, which in some cases meets criteria for dementia, screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B). Other management strategies all lack strong evidence.

Differential effects of testosterone and progesterone on the activation and retention of courtship behavior in sexual and parthenogenetic whiptail lizards.

Both testosterone (T) and progesterone (P) facilitate the expression of male-typical sexual behavior in a variety of animals, including rodents and lizards. In two species of whiptail lizards, Cnemidophorus inornatus and C. uniparens, both hormones elicit the full repertoire of courtship behavior. However, the relative efficacy of the two hormones is unknown. In Experiments 1 and 2 we assessed differences in capacity of exogenous T and P to induce male-typical courtship behavior in gonadectomized whiptail lizards. In both species, individuals implanted with T showed more frequent courtship behavior relative to those implanted with P or cholesterol. In Experiments 3 and 4 we examined whether T and P differentially affected the retention of courtship behavior following implant removal. In both species, individuals implanted with T showed more courtship behavior following implant removal than those previously given P. In these experiments, implants were removed at a time when individuals in both groups were behaviorally similar; therefore, the differences in behavior following implant removal were not due to differences in the amount of courtship experience. Taken together, the hormone that was more effective at activating courtship behavior was also more effective at maintaining courtship behavior following implant removal. In summary, though both T and P can elicit identical sexual behaviors in both whiptail species, T has a greater and more lasting effect on courtship behavior and possibly on the neural circuits underlying courtship behavior.