Abstract Introduction In advanced amyotrophic lateral sclerosis (ALS), eye movements often represent the last channel for intentional communication. While oculomotor function has traditionally been considered relatively preserved, emerging evidence indicates progressive impairment in long-term survivors on tracheostomy-invasive ventilation (TIV). As a result, eye-based communication may become increasingly unreliable before complete loss, challenging clinical decision-making and advance care planning (ACP). Methods We conducted a case-based topical review integrating clinical observation and literature to examine the trajectory of oculomotor decline, its impact on communication, and implications for treatment decisions. Three patients with ALS receiving TIV in a home-care setting illustrate key clinical and ethical challenges. Results Across cases and literature, oculomotor decline followed a gradual trajectory from effective eye-tracking communication to a complete locked-in syndrome. We identify a transitional phase of communicative ambiguity , in which residual ocular signals persist but can no longer be reliably attributed to intentional, patient-controlled communication. This phase is characterized by increasing inconsistency of signals and a divergence between observable responses and their interpretive certainty, creating uncertainty in assessing patient preferences. Implications Communicative ambiguity represents a clinically underrecognized but critical threshold in advanced ALS, marking the transition from direct patient autonomy to interpretative and surrogate-based decision-making. Failure to recognize this phase risks misinterpretation of patient intent and may undermine goal-concordant care. Timely and iterative ACP, initiated before communication becomes unreliable, is essential. We further propose four clinical pathways for treatment goal conversations, highlighting their differing implications for timing, symptom burden, and ethical decision-making.

Amyotrophic lateral sclerosis (ALS) is the most common adult-onset motor neuron disease, yet therapeutic progress remains slow due to pronounced biological heterogeneity. Here, we present a high-resolution proteomic map of cerebrospinal fluid (CSF) in a clinically well-characterized cohort of 93 individuals with ALS and 101 controls, defining molecular differences. Building on this landscape, unsupervised analysis revealed two reproducible ALS subtypes: an immune-enriched alpha subtype and a synapto-axonal beta subtype, further validated in an independent cohort (n=43 ALS). The alpha subtype was associated with higher neurofilament concentrations, whereas the beta subtype showed slower disease progression, indicating distinct pathological trajectories. We further derived a five-protein classifier (PARK7, PTPRS, ATRN, CNTN1, PCSK1N) that robustly discriminated subtypes across cohorts (AUC 0.951 ± 0.007). Together, this work defines the CSF proteomic landscape of ALS and establishes a foundation for molecular stratification in precision therapy and clinical trial design.

Background Parkinson’s disease (PD) is a complex neurodegenerative disorder characterized by motor and non-motor symptoms. Early diagnosis remains challenging due to the lack of reliable, non-invasive biomarkers. Here, we explored the potential of tear fluid (TF) as a diagnostic source by profiling its microRNA (miRNA) content. Methods The study included a discovery (8 PD, 7 healthy controls (HC)) and a replication cohort (9 PD, 9 HC). miRNA expression was assessed using TaqMan Human MicroRNA arrays. Independent in-silico validation was conducted using a qPCR-based miRNA array dataset comprising pooled cDNA samples from controls (n = 10) and PD patients (n = 29). The relationship between microRNA expression and composite clinical scores in PD patients was explored. Target gene prediction, pathway enrichment, and interaction network analyses were performed. Results The t-RNA-derived miR-1274b was consistently upregulated in the TF of PD patients across the discovery and replication cohorts, with additional in-silico support from the independent dataset. Increased expression was particularly evident in a PD subgroup characterized by combined non-motor autonomic symptoms. Predicted target genes were associated with neurodegeneration and cellular dysfunction. Over-representation analysis highlighted pathways related to negative regulation of synaptic transmission, while network analysis revealed interactions between miRNA targets and key PD-related genes, supporting a potential role in disease mechanisms. Conclusions Our findings identify miR-1274b as a TF-based miRNA associated with PD, supporting its potential as a non-invasive biomarker. Further studies with larger cohorts and other neurodegenerative diseases are needed to validate these results and explore their clinical applicability.

Abstract Background Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease, leading to an inexorable decline in voluntary muscle function, and finally to death within 2–4 years. The provision of professional ALS care is a multifaceted and continually evolving challenge, including the management of symptoms, advanced care planning, and the provision of psychosocial support. The core objective is to minimize suffering by optimizing symptom management and preserving quality of life. European and German guidelines recommend a specialized, multidisciplinary, and multiprofessional team, including collaborations with palliative care providers. While this is a validated approach to ensure optimal care and patient satisfaction, real-world experience suggests that the German healthcare system may not fully meet these requirements. Methods This study assessed resources of specialized ALS centres in Germany, focusing on the structural prerequisites for the provision of multidimensional care and collaboration with specialised palliative care (SPC) providers. A mixed methods design was used, comprising remote video interviews with neurologists specialized in ALS, including standardised questions and an open section. Results Sixteen neurologists representing their ALS centres were interviewed. The findings indicated a substantial discrepancy in the allocation of time and personnel resources among the centres. The majority of interviewees regarded resources to be inadequate and reported deficiencies in multidisciplinarity and networking. Consequently, certain components of ALS care - particularly psychosocial concerns - have been documented as being occasionally disregarded due to limitations in time or human resources. A number of interviewees expressed criticism regarding the inadequate access to and suboptimal collaboration with SPC providers. The compensation for patient care and interprofessional communication was not perceived as cost-effective. Conclusions Our results suggest that limited resources may prevent the provision of guideline-based care for people living with ALS and their families, even in specialized outpatient clinics. To facilitate the delivery of comprehensive care by ALS centers throughout the entire disease course, the establishment of operational standards concerning their multi-professional staffing and adequate compensation is imperative. Further research is needed to develop feasible concepts of how specialized neurological palliative care can be made reliably accessible to all patients in need.

The real-time quaking-induced conversion (RT-QuIC) assay has revolutionized prion disease diagnosis by detecting amyloidogenic PrP conformers in different tissue types and body fluids. Recently, we achieved a breakthrough by detecting amyloidogenic PrP conformers in tear fluid (TF), a non-invasive biofluid, warranting further evaluation. We refined our RT-QuIC protocol to assess seeding conversion efficiency using various recombinant substrates, including full-length human (FL Hu), and mutant versions linked to genetic prion diseases, such as E200K and D178N, in both CSF and TF samples. Our study included patients with sporadic and familial prion diseases. FL Hu E200K showed the highest seeding efficiency in cerebrospinal fluid (CSF), with sensitivity increasing from 78 to 93

BackgroundDefining motor phenotypes in amyotrophic lateral sclerosis (ALS) is important for individualized care and optimal therapeutic trial design. The "ALS-OPM" classification is based on the onset region (O), the propagation of motor symptoms (P), and the degree of clinical upper (UMN) and/or lower (LMN) motor neuron dysfunction (M).MethodsAn international ALS expert focus group was held in September 2025, followed by a consensus process through which revisions of the OPM classification were finalized.ResultsOnset (O1-4) identifies first motor symptoms as relating to the head (O1), distal/proximal arm (O2d/p), respiratory/axial trunk (O3r/a), or distal/proximal leg (O4d/p). Onset symptoms are defined by weakness or slowed, poorly coordinated voluntary movements in the muscles of the head, arm, trunk, or leg, including dysarthria, dysphagia, dysphonia, dyspnea, and axial instability. Propagation (P1(n)) or absence of propagation (P0(n)) of motor symptoms from the onset region to another body region are designated, where n denotes the number of months from onset to propagation or assessment. The degree of UMN dysfunction (slowed, poorly coordinated voluntary movements, hyperreflexia and/or spastic muscle tone, emotional lability) and/or LMN dysfunction (weakness with associated muscle atrophy) is classified as follows: balanced UMN and LMN dysfunction (M0); dominant (M1d) or pure UMN dysfunction (M1p); dominant (M2d) or pure LMN dysfunction (M2p); and dissociated UMN/LMN dysfunction (M3), in which the arms and legs predominantly show LMN and UMN involvement, respectively.ConclusionThe revised ALS-OPM classification aims to make it routine, practical and feasible to capture phenotype in clinical practice and therapeutic trials.

Detection of alpha-synuclein (α-Syn) seeding activity in tear fluid (TF) offers a promising non-invasive biomarker for Parkinson’s disease (PD). α-Syn seeding amplification assay (αSynSAA) detected seeding activity in 67% of PD-TF, while non-synucleinopathy samples remained negative. Electron microscopy of seeding-positive end products revealed fibrillar structures morphologically consistent with results of αSynSAA. αSynSAA effectively distinguished PD from controls and prion diseases based on seeding activity in TF.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by the spread of muscle weakness across body regions. ROCK-ALS was a multicenter, placebo-controlled phase 2 trial assessing the safety, tolerability, and efficacy of the Rho kinase inhibitor fasudil in ALS patients. A key exploratory objective was to evaluate fasudil's effect on the spread of muscle weakness using the Motor Unit Number Index (MUNIX), an established, quantitative electrophysiological biomarker of lower motor neuron integrity. MUNIX was assessed in 10 muscles at baseline, day 26, day 90, and day 180. In the present post-hoc analysis, correlations were assessed between baseline serum biomarkers—neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP)—and baseline clinical measures (ALSFRS-R, slow vital capacity, and MUNIX-10 sum scores) as well as their monthly rates of change, to explore potential prognostic relationships. For the analysis of disease spreading, muscles were classified as newly affected based on MUNIX decline relative to contralateral values or prior measurements, using thresholds of ≥10%, ≥20%, or ≥30%. Out of 118 participants included in the intention-to-treat population, 78 had full MUNIX datasets at baseline, and 67 had at least one follow-up. Baseline MUNIX-10 sum scores correlated with subsequent ALSFRS-R decline, suggesting prognostic value. Additionally, at day 90, fasudil significantly reduced the number of newly affected muscles compared to placebo in a dose-dependent manner over different thresholds. This supports MUNIX as a sensitive biomarker for monitoring disease spreading and demonstrates that fasudil may attenuate the progression of lower motor neuron involvement in ALS. Trial registration number: NCT03792490 (ClinicalTrials.gov); 2017-003676-31 (Eudra-CT).

BackgroundChronic inflammatory bowel diseases, encompassing Crohn's disease and ulcerative colitis, are characterized by persistent inflammation of the gastrointestinal tract. While traditionally regarded as confined to the gut, the systemic nature of inflammatory bowel disease has been increasingly recognized. The nervous system has garnered particular attention due to molecular and clinical evidence suggesting a potential interplay between inflammatory bowel disease and neurodegenerative diseases. Inflammatory bowel disease patients have a higher risk of developing neurological disorders such as Parkinson's disease, all-cause dementia, and multiple sclerosis. Still, causative molecular mechanisms are poorly understood. Neurofilament light chain (NfL) has been established as a disease-independent biomarker of axonal damage reflecting neurodegeneration.MethodsIn this pilot study, we assessed molecular evidence of neurodegeneration by measuring serum NfL in a single-molecule array using the HD-X SIMOA platform (Quanterix, MA, USA) and employing correlation with clinical data in forty-nine patients with histopathologically confirmed inflammatory bowel disease. In total, 24 Crohn's disease patients, 25 ulcerative colitis patients, and 23 controls, aged 18-79 years, were included.ResultsWe found an age-dependency of serological NfL levels, however, no apparent differences between disease groups and controls. Crohn's disease patients showed a slower age-dependent incline in serological NfL compared to control subjects (p = 0.03). No correlation of NfL with disease duration, disease severity, or inflammatory bowel disease treatment was found.ConclusionsA slower age-dependent increase in serological NfL levels was found in Crohn's disease patients compared to control subjects. Larger studies assessing additional markers of neurodegeneration may be instrumental in addressing this question in the future.

Objective: To define the minimum important slowing (MIS) of ALS progression that patients would expect from disease-modifying drug treatment in ALS. Methods: In a survey of ALS patients, the MIS in ALS progression (change in the ALS Functional Rating Scale-Revised, ALSFRS-R) was assessed by asking: "At what point of slowing of ALS, as determined by the ALSFRS-R, do you consider a drug to be important?" Data were collected during clinic visits or remotely via the ALS App. Participants were differentiated in the prognostic groups of slower (<0.5), intermediate (≥0.5 and ≤1.0), or faster (>1.0) ALS progression (ALSPR; ALSFRS-R/month). Results: Of 522 participants (ALS App, n = 397; clinic, n = 125), 395 (75.7%) completed the survey, while 127 (24.3%) selected the option "cannot estimate". The distribution of MIS was as follows: modest slowing of ALS progression (5% and 10% slowing, n = 146 patients, 36.9%), moderate slowing (20%, 30%, and 40% slowing, n = 135, 34.2%), and major slowing (≥50% slowing, n = 114, 28.9%). Median MIS was 20% (IQR 10-50%). Patients with faster ALSPR more frequently assessed a major slowing as the MIS (n = 18, 36.0%) compared to those with slower ALSPR (n = 54, 25.2%). Conclusion: A considerable number of participants viewed a modest slowing in ALS progression as the MIS, followed closely by preferences for moderate and major slowing. Expectations varied according to patients' individual ALS progression. These insights may inform the design of future clinical trials in ALS. Study limitations include potential selection and response biases, as well as the predominantly remote digital assessment.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by the spread of muscle weakness across body regions. The ROCK-ALS trial was a multicenter, randomized, double-blind, placebo-controlled phase 2 study assessing the safety, tolerability, and efficacy of the Rho kinase inhibitor fasudil as an add-on to riluzole in ALS patients. A key exploratory objective was to evaluate fasudil's effect on the spread of muscle weakness using the Motor Unit Number Index (MUNIX), a quantitative electrophysiological biomarker of lower motor neuron integrity. MUNIX was assessed in 10 muscles (5 on each body side) at baseline, day 26, day 90, and day 180. Correlations were assessed between baseline serum biomarkers-neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP)-and baseline clinical measures (ALSFRS-R, slow vital capacity, and MUNIX sum scores) as well as their monthly rates of change, to explore potential prognostic relationships. For the analysis of disease spreading, muscles were classified as newly affected based on MUNIX decline relative to contralateral values or prior measurements, using thresholds of ≥10%, ≥20%, or ≥30%. 118 participants were included in the intention-to-treat population, 78 had full MUNIX datasets at baseline and 67 had at least one follow-up. Baseline MUNIX sum scores correlated with subsequent ALSFRS-R decline, suggesting prognostic value. Additionally, at day 90, fasudil significantly reduced the number of newly affected muscles compared to placebo in a dose dependent manner over different thresholds. These findings support MUNIX as a sensitive biomarker for monitoring disease spreading and demonstrate that fasudil may attenuate the progression of lower motor neuron involvement in ALS.

OBJECTIVE:Tofersen is the first effective and approved therapy for superoxide dismutase 1 (SOD1)-associated amyotrophic lateral sclerosis (ALS [SOD1-ALS]). Following treatment with tofersen, neurofilament levels in patients' cerebrospinal fluid (CSF) and serum seem to respond earlier than clinical parameters. This evidence prompted us to hypothesize that this novel treatment could provide an opportunity to identify additional biomarkers responsive to therapy in SOD1-ALS. METHODS:We investigated a panel of 120 neural, glial, and inflammatory markers in CSF and serum samples longitudinally collected from a total of 28 SOD1-ALS patients at baseline, and after 3, 6 and 12 months of treatment with tofersen, followed by validation with conventional methodology. RESULTS:We identified a set of proteins, including neurofilament light chain, neurofilament heavy chain, amyloid-beta 1-40 and amyloid-beta 1-42, neuropeptide Y (NPY), and ubiquitin C-terminal hydrolase L1 (UCHL1), whose CSF levels both differed between SOD1-ALS and the control group, and were responsive to tofersen at 3 and 6 months after treatment initiation. Another group of markers, including the neuropentraxin (NPTX) family members NPTX1, NPTX2 and NPTXR, did not separate untreated SOD1-ALS from controls, but was responsive to tofersen. At 12 months on tofersen the levels of neurofilament light chain, neurofilament heavy chain, NPTX1, NPTX2, and NPTXR remained reduced compared with baseline, and correlated with the clinical response to tofersen. Consistent with increasing CSF pleocytosis and intrathecal immunoglobulin production, inflammatory markers were significantly increased after 12 months of treatment. INTERPRETATION:Our results highlight a complex, time-dependent differential response of CSF biomarkers to tofersen treatment, and may pave the way for developing a panel of responsive proteins to make biomarker endpoints more robust in clinical trials for SOD1-ALS and beyond. ANN NEUROL 2025;98:1318-1334.

In amyotrophic lateral sclerosis (ALS), heterogeneity of motor phenotypes is a fundamental hallmark of the disease. Distinct ALS phenotypes were associated with a different progression and survival. Despite its relevance for clinical practice and research, there is no broader consensus on the classification of ALS phenotypes. An expert consensus process for the classification of ALS motor phenotypes was performed from May 2023 to December 2024. A three-determinant anatomical classification was proposed which is based on the (1) region of onset (O), (2) the propagation of motor symptoms (P), and (3) the degree of upper (UMN) and/or lower motor neuron (LMN) dysfunction (M). Accordingly, this classification is referred to as the “OPM classification”. Onset phenotypes differentiate the site of first motor symptoms: O1) head onset; O2d) distal arm onset; O2p) proximal arm onset; O3r) trunk respiratory onset; O3a) trunk axial onset; O4d) distal leg onset; O4p) proximal leg onset. Propagation phenotypes differentiate the temporal propagation of motor symptoms from the site of onset to another, vertically distant body region: PE) earlier propagation (within 12 months of symptom onset); PL) later propagation (without propagation within 12 months of symptom onset), including the established phenotypes of “progressive bulbar paralysis” (O1, PL), “flail-arm syndrome” (O2p, PL), and “flail-leg syndrome” (O4d, PL); PN) propagation not yet classifiable as time since symptom onset is less than 12 months. Phenotypes of motor neuron dysfunction differentiate the degree of UMN and/or LMN dysfunction: M0) balanced UMN and LMN dysfunction; M1d) dominant UMN dysfunction; M1p) pure UMN dysfunction (“primary lateral sclerosis”, PLS); M2d) dominant LMN dysfunction; M2p) pure LMN dysfunction (“progressive muscle atrophy”, PMA); M3) dissociated motor neuron dysfunction with dominant LMN and UMN dysfunction of the arms and legs (“brachial amyotrophic spastic paraparesis”), respectively. This consensus process aimed to standardize the clinical description of ALS motor phenotypes in clinical practice and research – based on the onset region, propagation pattern, and motor neuron dysfunction. This “OPM classification” contributes to specifying the prognosis, to defining the inclusion or stratification criteria in clinical trials and to correlate phenotypes with the underlying disease mechanisms of ALS.

Detection of alpha-synuclein seeding activity in tear fluid (TF) might provide a promising non-invasive biomarker for Parkinson's disease (PD) diagnosis. In this study, we applied the alpha-synuclein seeding amplification assay (aSynSAA) to detect misfolded alpha-synuclein (aSyn) aggregation in TF from PD patients. The discovery cohort included 11 PD patients and 13 controls, and the validation cohort consisted of 9 PD patients and 11 controls without synucleinopathies. The aSynSAA yielded positive results in over 55% of PD patients. These findings were confirmed in a second cohort, including patients with prion diseases as a negative control for synuclein pathology. Our results demonstrate for the first time the ability of aSynSAA to distinguish between PD and control groups in TF, with PD showing the highest seeding activity compared to prion disease and control groups. Further comparisons between cerebrospinal fluid (CSF) and TF samples from the same individuals revealed consistent seeding results across both biofluids. These findings highlight the potential of tear fluid as a novel, accessible medium for detecting Lewy body-specific misfolded synuclein aggregation in PD, which could aid in early diagnosis and disease progression monitoring. ### Competing Interest Statement The authors have declared no competing interest.

Parkinson's disease (PD), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP) are neurodegenerative disorders diagnosed by clinical criteria with limited diagnostic specificity in early stages. Diagnostic biomarkers facilitating early and precise diagnosis are needed. Tear fluid (TF) is an easily accessible body fluid reflecting pathophysiological changes in ocular and systemic diseases. In this exploratory study, we investigate TF as a non-invasive source of disease-specific miRNAs for PD, MSA, and PSP. We demonstrate reduced TF production in PD patients. Using a real-time quantitative PCR-based array targeting 1113 miRNAs, we identified 55 exclusively expressed in PD, 35 in PSP, and 14 in MSA, respectively. Several of these have previously been identified in other biofluids. Overrepresentation analysis of target genes showed apoptotic and cell differentiation pathways as common targets. While these findings suggest that miRNA alterations in TF might reflect disease mechanisms in PD and atypical Parkinsonian syndromes, the exploratory character of the study combined with the use of pooled samples, indicates the need for further validation. The small sample size highlights the importance of follow-up studies with larger, more definitive cohorts to confirm the potential of these miRNAs as reliable biomarkers.

OBJECTIVE:To investigate self-assessment of the amyotrophic lateral sclerosis functional rating scale-revised (ALSFRS-R) using the patient's smartphone and to analyze non-inferiority to clinic assessment. METHODS:In an observational study, ALSFRS-R data being remotely collected on a mobile application (App-ALSFRS-R) were compared to ALSFRS-R captured during clinic visits (clinic-ALSFRS-R). ALS progression rate (ALSPR)-as calculated by the monthly decline of ALSFRS-R-and its intrasubject variability (ALSPR-ISV) between ratings were used to compare both cohorts. To investigate non-inferiority of App-ALSFRS-R data, a non-inferiority margin was determined. RESULTS:A total of 691 ALS patients using the ALS-App and 1895 patients with clinic assessments were included. Clinical characteristics for the App-ALSFRS-R and clinic-ALSFRS-R cohorts were as follows: Mean age 60.45 (SD 10.43) and 63.69 (SD 11.30) years (p < 0.001), disease duration 38.7 (SD 37.68) and 56.75 (SD 54.34) months (p < 0.001) and ALSPR 0.72 and 0.59 (p < 0.001), respectively. A paired sample analysis of ALSPR-ISV was applicable for 398 patients with clinic as well as app assessments and did not show a significant difference (IQR 0.12 [CI 0.11, 0.14] vs 0.12 [CI 0.11, 0.14], p = 0.24; Cohen's d = 0.06). CI of IQR for App-ALSFRS-R was below the predefined non-inferiority margin of 0.15 IQR, demonstrating non-inferiority. CONCLUSIONS:Patients using a mobile application for remote digital self-assessment of the ALSFRS-R revealed younger age, earlier disease course, and faster ALS progression. The finding of non-inferiority of App-ALSFRS-R assessments underscores, that data collection using the ALS-App on the patient's smartphone can serve as additional source of ALSFRS-R in ALS research and clinical practice.

Background: Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) exhibit significant clinical, genetic and neuropathological abnormalities, and are regarded as belonging to a common disease spectrum, referred to as the ALS-FTD spectrum disorders. Our understanding of the underlying mechanisms of these diseases has advanced significantly, including molecular neuropathology, genetics and molecular pathophysiology. The heterogeneity of these diseases poses significant challenges to translational research and drug development, particularly in sporadic cases. Consequently, there is an urgent need to improve patient stratification for the successful execution of future clinical trials. Methods/Results: We here describe the study design of the DESCRIBE-ALS/FTD study which aims to address this research gap by undertaking a systematic sampling of patients from the ALS FTD spectrum, encompassing all possible disease variants. The main objective of the study is to systematically document detailed cross-sectional phenotyping and the temporal progression of motor and neuropsychological abnormalities that occur in both ALS and FTD. Additionally, it seeks to systematically correlate these abnormalities with genetics and potentially predictive biomarkers including longitudinal biomaterial sampling, brain imaging and brain banking. Furthermore, first-degree relatives of patients with disease-causing gene variants undergo the same assessments to also sample presymptomatic risk gene carriers. Conclusion: With this prospective registry study we aim to generate datasets which will help researchers identifying different disease traits in people with sporadic and genetic ALS and FTD and to develop biomarkers to identify preclinical and prodromal disease stages.

BACKGROUND:In amyotrophic lateral sclerosis (ALS), dextromethorphan/quinidine (DMQ) has been reported to reduce bulbar symptoms, including dysarthria and dysphagia. However, data on patients' perceptions of DMQ treatment are limited. METHODS:Data on DMQ treatment were collected from 1065 ALS patients treated at 13 ALS centers between 10-2015 and 06-2025. Patient-reported outcome measures (PROM) of 179 participants were remotely assessed via the "ALS App". PROM included the self-explanatory version of the ALS Functional Rating Scale (ALSFRS-R-SE), the Net Promoter Score (NPS); and Treatment Satisfaction Questionnaire for Medication (TSQM-9). RESULTS:Mean disease duration was 29.3 months (SD 38.1). ALS progression before treatment was 0.82 points/month (ALSFRS-R). Mean DMQ treatment duration was 8.4 months (SD 10.8), including 35.2% (n = 374) of shorter (<3 months), 35.3% (n = 375) of longer (3-9 months), and 29.5% (n = 313) of very long DMQ treatment (>9 months). Patients' recommendation (n = 178) was positive (NPS: +23) with higher scores after very long DMQ treatment (NPS +37) compared to longer (NPS +15) and shorter treatment (NPS +7.5), respectively. TSQM-9 scores (n = 163) demonstrated high satisfaction for effectiveness 60.0 (SD 25.9), convenience 73.8 (SD 18.2), and global satisfaction 63.4 (SD 29.8). INTERPRETATION:The positive perception in PROM underscores the value of DMQ as an individualized treatment option for bulbar symptoms in ALS. However, shortage of clinical data, online assessment, and selection biases are among the limitations of this study that need to be addressed in further investigations.

The diagnosis of Amyotrophic Lateral Sclerosis (ALS) remains challenging, particularly in early stages, where characteristic symptoms may be subtle and nonspecific. The development of disease-specific and clinically validated biomarkers is crucial to optimize diagnosis. Here, we explored tear fluid (TF) as a promising ALS biomarker source, given its accessibility, anatomical proximity to the brainstem as an important site of neurodegeneration, and proven discriminative power in other neurodegenerative diseases. Using a discovery approach, we profiled protein abundance in TF of ALS patients (n = 49) and controls (n = 54) via data-independent acquisition mass spectrometry. Biostatistical analysis and machine learning identified differential protein abundance and pathways in ALS, leading to a protein signature. These proteins were validated by Western blot in an independent cohort (ALS n = 51; controls n = 52), and their discriminatory performance was assessed in-silico employing machine learning. 876 proteins were consistently detected in TF, with 106 differentially abundant in ALS. A six-protein signature, including CRYM, PFKL, CAPZA2, ALDH16A1, SERPINC1, and HP, exhibited discriminatory potential. We replicated significant differences of SERPINC1 and HP levels between ALS and controls across the cohorts, and their combination yielded the best in-silico performance. Overall, this investigation of TF proteomics in ALS and controls revealed dysregulated proteins and pathways, highlighting inflammation as a key disease feature, strengthening the potential of TF as a source for biomarker discovery.