stroke misdiagnosis disproportionate in the young says Washington Post

David Newman-Toker toker at JHU.EDU
Thu Jun 19 11:37:11 UTC 2014


Thanks David. So I gather you think that these two CDRs below addressing stroke diagnosis in patients with headache and dizziness, respectively, are lacking some combination of good performance, ease of use, or buy in? ("rule has good performance, easy to use, and is bought into by both emergency physicians and neurologists")

Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA : the journal of the American Medical Association 2013;310:1248-55.

Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2013;20:986-96.



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<mailto: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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From: David Gordon, M.D. [mailto:davidc.gordon at duke.edu]
Sent: Wednesday, June 18, 2014 9:40 AM
To: Society to Improve Diagnosis in Medicine; David Newman-Toker
Subject: RE: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post

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<mailto: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<mailto: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>


Confidentiality Notice: The information contained in this email is intended for the confidential use of the above named recipient. If the reader of this message is not the intended recipient or person responsible for delivering it to the intended recipient, you are hereby notified that you have received this communication in error, and that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this in error, please notify the sender immediately by telephone at the number set forth above and destroy this email message. Thank you.


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