stroke misdiagnosis disproportionate in the young says Washington Post

Beth Conlin bconlin at GMAIL.COM
Wed Jun 18 15:11:43 UTC 2014


One key point that is emphasized in the article and not in this discussion
is that the specific focus was young *women*.  Newman-Toker article:
"Younger patients [11, 20], women [21], minorities [22], and those triaged
to lower acuity care or seen in non-teaching hospitals [23] may be at
higher risk."  "Odds of a probable misdiagnosis were lower among men (OR
0.75)"

The Post article discuss specific possible risk factors from hormone
treatment possibly contributing to stroke prevalence, and also to frequent
misdiagnosis as migraines, and my perception is that migraines are a much
more common diagnosis for women.  This seems to be, in many ways, in the
same vein as the problems with diagnosing acute heart symptoms in women.

Any comments on the gender perspective?


On Wed, Jun 18, 2014 at 9:39 AM, David Gordon, M.D. <davidc.gordon at duke.edu>
wrote:

>  David,
>
>  A real challenge here is trying to separate the signal from the noise,
> and when it comes to neurologic complaints, there is unfortunately a lot of
> noise in emergency departments. Overcrowding and financial pressures
> further compound the difficulty of who requires the full work-up.
>
>  I think risk stratification is key to this issue. We have imperfect but
> overall good processes and tools in place for the risk stratification of
> ACS and pulmonary embolism. As an emergency physician, I don't feel I have
> the same cognitive tools available for independently risk stratifying
> TIA/stroke. I am fortunate to work in a clinical environment where I have
> ready access to neurology consultation to assist in the process and an
> observation protocol for equivocal/intermediate cases, but I gather to say
> this is far from the norm.
>
>  As far as the treatment of neurologic complaints in the emergency
> setting, we need more evidence. It is going to take prospective analysis of
> all-comers to the ED with stroke-like symptoms to better understand who
> needs immediate work-up and who can be safely discharged. Perhaps we will
> end up with 2 different stratification tools- one for the young and one for
> the old.
>
>  As far as whether diagnostic aids will be utilized or ignored due to
> CDRs, I think it depends. If the rule has good performance, easy to use,
> and is bought into by both emergency physicians and neurologists, I do
> think it would be readily employed - especially if the evidence becomes
> increasingly convincing that the epidemiology of stroke is changing (or
> becoming better understood) and young patient's are being misdiagnosed.
>
>  -David
>
>  David Gordon, MD
> Associate Professor
> Undergraduate Education Director
> Division of Emergency Medicine
> Duke University
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>    ------------------------------
> *From:* David Newman-Toker [toker at JHU.EDU]
>
> *Sent:* Tuesday, June 17, 2014 2:56 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] stroke misdiagnosis disproportionate in the young
> says Washington Post
>
>   Stroke is a major public health problem, and recent work suggests young
> patients are having more strokes, with rates rising alarmingly in recent
> years, according to an article in today’s Washington Post…
>
>
>
>
> http://www.washingtonpost.com/national/health-science/strokes-long-on-the-decline-among-the-elderly-are-rising-among-younger-adults/2014/06/16/f1f54538-e5d9-11e3-a86b-362fd5443d19_story.html
>
>
>
> They are also much more likely to be misdiagnosed (7-fold greater risk in
> those 18-45 relative to those >75)…
>
>
>
>
> http://www.degruyter.com/view/j/dx.2014.1.issue-2/dx-2013-0038/dx-2013-0038.xml
>
>
>
> Thoughts?
>
>
>
> David
>
>
>
>
>
> David E. Newman-Toker, MD, PhD
> Associate Professor, Department of Neurology
> Johns Hopkins Hospital, Meyer 8-154; 600 North Wolfe Street, Baltimore, MD
> 21287
>
> Email: toker at jhu.edu; 410-502-6270 (phone); 410-502-6265 (fax)
> Web address: Johns Hopkins Neurology (David Newman-Toker)
> <http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vestibular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Newman-Toker>
>
>
>
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