Stanford Health Care

Cognitive models of attention deficit hyperactivity disorder (ADHD) have traditionally centered on deficits in inhibitory control and motivation. A substantial body of empirical research supports impairments in both domains: children with ADHD exhibit elevated commission error rates, prolonged stop-signal reaction time, and a strong preference for smaller immediate rewards over larger delayed ones. In the first part of this review, we synthesize key findings from behavioral and task-state functional neuroimaging studies that characterize these deficits, highlighting how deficits in inhibitory control and motivation/reward systems manifest across tasks and contexts. We further examine evidence on the interplay between the two systems and how their interaction is altered in children with ADHD. In the second part, we introduce recent advances in cognitive and computational neuroscience that extend classic neurocognitive models by incorporating dynamic perspectives. Specifically, we describe the dynamic dual-control framework, which distinguishes between proactive and reactive inhibitory control, and highlight dynamics of trial-by-trial adaptive response strategy adjustment. We also review emerging computational models that can identify latent brain states and their evolution during task performance, revealing novel neurodynamic mechanisms that may underlie cognitive instability in ADHD. Additionally, we discuss pharmacological studies that shed light on how the inhibitory control and motivation/reward systems are modulated by medication. Finally, we address current limitations and challenges in ADHD research, with a particular focus on task-state functional neuroimaging, and propose future directions for advancing the field. By integrating dynamic modeling approaches with established neurocognitive frameworks, this review aims to deepen our understanding of the brain mechanisms underlying ADHD and to inform the development of more precise and effective interventions.

Shared decision-making (SDM) aligns treatment recommendations with patient values, and has been shown to positively affect surgical outcomes. We aimed to characterize the variation in levels of SDM among surgeons using CollaboRATE, a validated patient-reported tool for assessing SDM in clinical care. This multicenter retrospective cohort study analyzed American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Patient-Reported Outcomes (PRO) data from 30,957 surgical patients treated by 2,921 surgeons across 65 hospitals between 2020 to 2023. Patient-reported scores were analyzed to (1) characterize the distribution of patient scores, (2) explore the distribution of surgeon-level performance, and (3) identify patient, surgeon, and hospital-level factors associated with higher and lower performance. Multilevel logistic regression, adjusted for clustering at the hospital level, assessed factors associated with surgeon-level performance. Of patient responses, 64% reported adequate SDM (a composite score of 27). No single CollaboRATE domain disproportionately accounted for inadequate patient ratings. Among 977 surgeons, only 1.2% achieved mean scores of 27, whereas 80.6% of surgeons achieved a median score of 27. Multivariable analysis revealed that lower surgeon performance associated with male gender (OR 2.75, 95% CI [2.34-3.23]), cardiothoracic specialty (OR 5.78 [4.41-7.57], rural setting (OR 5.55 [1.19-25.82]), and greater than 31 years of practice (OR 2.29 [2.02-2.59]). Using CollaboRATE to describe surgeon-level variability will be useful for both benchmarking and targeted quality improvement. These results suggest SDM might be a modifiable skill warranting targeted improvement efforts and surgeon-specific training.

Respiratory involvement in facioscapulohumeral muscular dystrophy is a clinically relevant yet frequently underdiagnosed. Manifestations range from subclinical restrictive ventilatory impairment to sleep-disordered breathing and nocturnal hypoventilation, and contribute to reduced quality of life as well as increased morbidity and mortality. Restrictive patterns occur in approximately 10-45 % of patients and are primarily associated with early disease onset, greater clinical severity, spinal deformities, and loss of ambulation. Pathophysiology is multifactorial, involving respiratory muscle weakness, reduced chest wall compliance, upper airway instability, and sleep-related reductions in ventilatory drive. Importantly, sleep-disordered breathing may arise independently of overall motor impairment and can represent the earliest clinically relevant manifestation. Given the often clinically inapparent presentation, structured respiratory investigation is recommended. Spirometry with upright and supine forced vital capacity remains central to evaluation and should be complemented by blood gas analysis, respiratory muscle testing and nocturnal carbon dioxide monitoring. Management follows established neuromuscular principles: non-invasive ventilation is indicated for hypoventilation or hypercapnia, whereas continuous positive airway pressure is appropriate for isolated obstructive sleep apnoea. Early recognition through systematic screening is critical to enable timely intervention and optimize outcomes.