stroke misdiagnosis disproportionate in the young says Washington Post

David Newman-Toker toker at JHU.EDU
Thu Jun 19 11:42:32 UTC 2014


Supposedly it is real rather than increased ascertainment, and the fact that misdiagnosis is much greater in the young is compatible with that explanation (if there were greater ascertainment accounting for an 'apparent' increase in incidence, then you might expect that the missed stroke rate would be relatively similar to that in older patients, rather than 7-fold higher).

As I recall, the average time for new science to penetrate medical practice is nearly two decades --- roughly the lifespan for a generation of physicians, perhaps.


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: Carroll, Thomas [mailto:Thomas_Carroll at URMC.Rochester.edu]
Sent: Tuesday, June 17, 2014 8:13 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; David Newman-Toker
Subject: RE: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post

Two things:

Does anyone have a feel for if this is a real increase (and if so, do you have an explanation) or a case of increased recognition leading to an apparent increased incidence?

Regardless of the answer to the first question, the problem is one of adjusting our pretest probability for stroke in this age group. Not an easy task. Probably all it will take is for a generation or two of physicians to die (kidding, sort of).

-----Original Message-----
From: David Newman-Toker [toker at JHU.EDU]
Received: Tuesday, 17 Jun 2014, 6:53pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> [IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG]
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post
I agree, Pat. Do you (or others) think that clinicians are also less likely to use (or think of using) clinical decision rules related to stroke (e.g., Ottawa SAH rule or HINTS) in those same patients? If so, do we have an even bigger problem than we imagined --- i.e., that even if we convince people to 'routinely' use evidence-based diagnostic decision rules for stroke (or other similar diagnostic problems where errors are more frequent than we'd like), that their cognitive dispositions to respond will lead to selective non-use of these rules in more atypical (i.e., less representative) cases?

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<https://urldefense.proofpoint.com/v2/url?u=http-3A__mailto-3Atoker-40jhu.edu&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=jR63K6Io7KB6rYLvPxAs11uyyVt0RiDZzSV97xsRPb0&e=>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.hopkinsmedicine.org_neurology-5Fneurosurgery_specialty-5Fareas_vestibular_profiles_team-5Fmember-5Fprofile_516F40C024FCA3D4B4B633D0E080FE1B_David-5FNewman-2DToker&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=_TQu_x8d8Mgp8tqbD69HdtwFYOolRCGBbUg0lH_OSzQ&e=>


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From: Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Sent: Tuesday, June 17, 2014 3:23 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post

Probably a number of factors involved, but principle among them are likely to be representativeness and ascertainment biases.
i.e. clinicians see what they expect to see, and expect stroke victims to be older.
Pat



From: David Newman-Toker [mailto:toker at JHU.EDU<https://urldefense.proofpoint.com/v2/url?u=http-3A__mailto-3Atoker-40JHU.EDU&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=06zMA2x-kV4q-6rLs3J1uVc-NGYz4dTmOUEDSJlTqJ4&e=>]
Sent: Tuesday, June 17, 2014 3:56 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<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.washingtonpost.com_national_health-2Dscience_strokes-2Dlong-2Don-2Dthe-2Ddecline-2Damong-2Dthe-2Delderly-2Dare-2Drising-2Damong-2Dyounger-2Dadults_2014_06_16_f1f54538-2De5d9-2D11e3-2Da86b-2D362fd5443d19-5Fstory.html&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=GH2jM6jRHwaZB_ENzFS0HPPXc1W3wBRJ0c782oFPENg&e=>

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<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.degruyter.com_view_j_dx.2014.1.issue-2D2_dx-2D2013-2D0038_dx-2D2013-2D0038.xml&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=nc6p1L7BLkCKBEGCfXV6YXYxGp_vObklweKII4sIK-w&e=>

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<https://urldefense.proofpoint.com/v2/url?u=http-3A__mailto-3Atoker-40jhu.edu&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=jR63K6Io7KB6rYLvPxAs11uyyVt0RiDZzSV97xsRPb0&e=>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.hopkinsmedicine.org_neurology-5Fneurosurgery_specialty-5Fareas_vestibular_profiles_team-5Fmember-5Fprofile_516F40C024FCA3D4B4B633D0E080FE1B_David-5FNewman-2DToker&d=AAMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=6UQeJyvbn5pEeVcNPSpZTW_XDQamCTfFt2g6O9GbIbo&s=_TQu_x8d8Mgp8tqbD69HdtwFYOolRCGBbUg0lH_OSzQ&e=>


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