Diagnostic impact of CSF biomarkers for Alzheimer's disease in a tertiary memory clinic  Flora H. Duits, Niels D. Prins, Afina W. Lemstra, Yolande A.L. Pijnenburg, Femke H. Bouwman, Charlotte E. Teunissen, Philip Scheltens, Wiesje M. van der Flier  Alzheimer's & Dementia: The Journal of the Alzheimer's Association  Volume 11, Issue 5, Pages 523-532 (May 2015) DOI: 10.1016/j.jalz.2014.05.1753 Copyright © 2015 The Alzheimer's Association Terms and Conditions

Fig. 1 Flow chart of study population. 492 patients with cognitive complaints presented in our memory clinic in 1 year. Several patients were excluded from the study: three patients did not give informed consent for the use of their clinical data for research purposes, in 22 patients cerebrospinal fluid (CSF) biomarkers were recently analyzed at their first visit at our memory clinic, in nine patients final clinical assessment by the neurologist—and therefore completion of the questionnaires—was not possible (i.e. when the results of the screening were only communicated by phone, with the patient's partner or the referring clinician), and in 19 cases questionnaires were incorrectly or not completed. Finally, 438 patients were included in the study. Displayed are separate paths for patients in which neurologists wished or did not wish to use the CSF biomarkers—with pie diagrams for the distribution of diagnoses in each group—and furthermore for patients with and without the performance of lumbar puncture (LP). The distribution of diagnoses was evidently different for the patients in which neurologists wished to use the CSF results compared with the group in which neurologists did not wish the CSF. The proportion of cases in which neurologists deemed CSF results important (i.e. for understanding the patient's pathology) after disclosure (in patients with CSF), or indicated CSF would have been useful (in patients without CSF), and proportion with consequences for patient management were higher in cases where neurologists had indicated beforehand they wished to know the results. Note that in some patients more than one consequence was indicated. Shown beneath the flow diagram are pie diagrams of all changed diagnoses (primary diagnoses shown) and the distribution of diagnoses of patients with other consequences for further management (such as imaging studies, pre-selection for a trial or consultation of another specialist). Alzheimer's & Dementia: The Journal of the Alzheimer's Association 2015 11, 523-532DOI: (10.1016/j.jalz.2014.05.1753) Copyright © 2015 The Alzheimer's Association Terms and Conditions

Fig. 2 Reasons for wishing to use cerebrospinal fluid (CSF; beforehand) and actually using CSF (after disclosure of CSF). In light grey: the frequencies of reasons for wishing to use CSF results, as indicated by neurologists before the disclosure of the results. Displayed are percentages of all cases in which neurologists indicated they wished to use CSF results (n = 326; 74% of all cases). In dark grey: frequencies of reasons for using CSF results, as indicated by neurologists after disclosure of the results. Displayed are percentages of all cases in which neurologists indicated to have used CSF results (n = 179; 51% of all cases with CSF). Note that clinicians could select more than one reason, therefore, percentages count to more than 100%. *Trial selection was in some cases a reason to know CSF results, as the possibility of inclusion in a trial could be dependent on values of CSF biomarkers. Alzheimer's & Dementia: The Journal of the Alzheimer's Association 2015 11, 523-532DOI: (10.1016/j.jalz.2014.05.1753) Copyright © 2015 The Alzheimer's Association Terms and Conditions

Fig. 3 Diagnostic confidence levels before and after the disclosure of cerebrospinal fluid (CSF) results. Displayed are confidence levels before disclosure of CSF results (in light grey), and confidence levels after the disclosure of CSF results (in dark grey) of the total study population (on the left), and stratified according to whether neurologists indicated beforehand they wished or did not wish to use the CSF results (on the right). The number of patients is indicated beneath the graph. Only patients with CSF and unchanged diagnosis after the disclosure of CSF were included in this analysis. Analyses were performed using univariate General linear models and general linear models for repeated measures, and were adjusted for clinician (entered as dummy variables in the model). Stars indicate significant differences. Alzheimer's & Dementia: The Journal of the Alzheimer's Association 2015 11, 523-532DOI: (10.1016/j.jalz.2014.05.1753) Copyright © 2015 The Alzheimer's Association Terms and Conditions