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Fullerton JL, Cosgrove CC, Rooney RA, Work LM. Extracellular vesicles and their microRNA cargo in ischaemic stroke. J Physiol 2023; 601:4907-4921. [PMID: 35421904 PMCID: PMC10952288 DOI: 10.1113/jp282050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/15/2022] [Indexed: 11/08/2022] Open
Abstract
Acute ischaemic stroke (AIS) is a leading cause of death and disability. MicroRNAs (miRNAs) are short non-coding RNAs which hold the potential to act as a novel biomarker in AIS. The majority of circulating miRNAs are actively encapsulated by extracellular vesicles (EVs) produced by many cells and organs endogenously. EVs released by mesenchymal stem cells (MSCs) have been extensively studied for their therapeutic potential. In health and disease, EVs are vital for intercellular communication, as the cargo within EVs can be exchanged between neighbouring cells or transported to distant sites. It is clear here from both current preclinical and clinical studies that AIS is associated with specific EV-derived miRNAs, including those transported via MSC-derived EVs. In addition, current studies provide evidence to show that modulating levels of specific EV-derived miRNAs in AIS provides a novel therapeutic potential of miRNAs in the treatment of stroke. Commonalities exist in altered miRNAs across preclinical and clinical studies. Of those EV-packaged miRNAs, miRNA-124 was described both as an EV-packaged biomarker and as a potential EV-loaded therapeutic in experimental models. Alterations of miRNA-17 family and miRNA-17-92 cluster were identified in preclinical, clinical and MSC-EV-mediated neuroprotection in experimental stroke. Finally, miRNA-30d and -30a were found to mediate therapeutic effect when overexpressed from MSC and implicated as a biomarker clinically. Combined, EV-derived miRNAs will further our understanding of the neuropathological processes triggered by AIS. In addition, this work will help determine the true clinical value of circulating EV-packaged miRNAs as biomarkers of AIS or as novel therapeutics in this setting.
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Affiliation(s)
- Josie L. Fullerton
- Institute of Cardiovascular and Medical Sciences College of Medical, Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Caitlin C. Cosgrove
- Institute of Cardiovascular and Medical Sciences College of Medical, Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Rebecca A. Rooney
- Institute of Cardiovascular and Medical Sciences College of Medical, Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Lorraine M. Work
- Institute of Cardiovascular and Medical Sciences College of Medical, Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
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Ohshiro Y. A New Neurological Screening Approach for Diagnosing Brainstem Infarction Using the Calling Method and Familiar Voices. Medicina (Kaunas) 2023; 59:1344. [PMID: 37512155 PMCID: PMC10383907 DOI: 10.3390/medicina59071344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
This report proposes a new approach to assess dysarthria in patients with brainstem infarction by involving familiar individuals. Collaboration provides valuable insights compared to subjective traditional methods. A man in his 70s presented with resolved positional vertigo. Standard neurological tests showed no abnormalities, and inquiries with the patient's friend did not reveal voice changes. While inquiring about voice changes with family, friends, and acquaintances is a common practice in clinical settings, our approach involved the patient calling out to his friend from a distance. Despite the physician detecting no abnormalities, the friend noticed a lower voice. Subsequent magnetic resonance imaging (MRI) confirmed brainstem infarction. Early and subtle symptoms of brainstem infarction pose a detection challenge and can lead to serious outcomes if overlooked. This report provides the first evidence that distance calling can detect subtle voice changes associated with brainstem infarction potentially overlooked by conventional neurological examinations, including inquiries with individuals familiar with the patient's voice. Detecting brainstem infarction in emergency department cases is often missed, but conducting MRIs on every patient is not feasible. This simple method may identify patients overlooked by conventional screening who should undergo neuroimaging such as MRI. Further research is needed, and involving non-professionals in assessments could significantly advance the diagnostic process.
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Affiliation(s)
- Yuzuru Ohshiro
- Department of Internal Medcine, Omoromachi Medical Center, Naha City 900-0011, Okinawa, Japan
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Miyagami T, Watari T, Harada T, Naito T. Medical Malpractice and Diagnostic Errors in Japanese Emergency Departments. West J Emerg Med 2023; 24:340-347. [PMID: 36976599 PMCID: PMC10047720 DOI: 10.5811/westjem.2022.11.55738] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 11/02/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Emergency departments (ED) are unpredictable and prone to diagnostic errors. In addition, non-emergency specialists often provide emergency care in Japan due to a lack of certified emergency specialists, making diagnostic errors and associated medical malpractice more likely. While several studies have investigated the medical malpractice related to diagnostic errors in EDs, only a few have focused on the conditions in Japan. This study examines diagnostic error-related medical malpractice lawsuits in Japanese EDs to understand how various factors contribute to diagnostic errors. METHODS We retrospectively examined data on medical lawsuits from 1961-2017 to identify types of diagnostic errors and initial and final diagnoses from non-trauma and trauma cases. RESULTS We evaluated 108 cases, of which 74 (68.5%) were diagnostic error cases. Twenty-eight of the diagnostic errors were trauma-related (37.8%). In 86.5% of these diagnostic error cases, the relevant errors were categorized as either missed or diagnosed incorrectly; the others were attributable to diagnostic delay. Cognitive factors (including faulty perception, cognitive biases, and failed heuristics) were associated with 91.7% of errors. Intracranial hemorrhage was the most common final diagnosis of trauma-related errors (42.9%), and the most common initial diagnoses of non-trauma-related errors were upper respiratory tract infection (21.7%), non-bleeding digestive tract disease (15.2%), and primary headache (10.9%). CONCLUSION In this study, the first to examine medical malpractice errors in Japanese EDs, we found that such claims are often developed from initial diagnoses of common diseases, such as upper respiratory tract infection, non-hemorrhagic gastrointestinal diseases, and headaches.
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Affiliation(s)
- Taiju Miyagami
- Juntendo University, Department of General Medicine, Bunkyō, Tokyo, Japan
| | - Takashi Watari
- Shimane University Hospital, General Medicine Center, Department of General Medicine, Izumo City, Shimane, Japan
- University of Michigan Medical School, Department of Medicine, Ann Arbor, Michigan, United States of America
| | - Taku Harada
- Nerima Hikarigaoka Hospital, Division of General Medicine, Tokyo, Japan
- Dokkyo Medical University Hospital, Department of Diagnostic and Generalist Medicine, Mibu, Shimotsuga, Tochigi, Japan
| | - Toshio Naito
- Juntendo University, Department of General Medicine, Bunkyō, Tokyo, Japan
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Fullerton JL, Thomas JM, Gonzalez-Trueba L, Trivett C, van Kralingen JC, Allan SM, Quinn TJ, Work LM. Systematic review: Association between circulating microRNA expression & stroke. J Cereb Blood Flow Metab 2022; 42:935-951. [PMID: 35240874 PMCID: PMC9121526 DOI: 10.1177/0271678x221085090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 12/22/2022]
Abstract
This systematic review aimed to establish the range and quality of clinical and preclinical evidence supporting the association of individual microRNAs, and the use of microRNA expression in the diagnosis and prognosis of ischaemic or haemorrhagic stroke. Electronic databases were searched from 1993 to October 2021, using key words relevant to concepts of stroke and microRNA. Studies that met specific inclusion and exclusion criteria were selected for data extraction. To minimise erroneous associations, findings were restricted to microRNAs reported to change in more than two independent studies. Of the papers assessed, 155 papers reported a change in microRNA expression observed in more than two independent studies. In ischaemic studies, two microRNAs were consistently differentially expressed in clinical samples (miR-29b & miR-146a) and four were altered in preclinical samples (miR-137, miR-146a, miR-181b & miR-223-3p). Across clinical and preclinical haemorrhagic studies, four microRNAs were downregulated consistently (miR-26a, miR-126, miR-146a & miR-155). Across included studies, miR-126 and miR-146a were the only two microRNAs to be differentially expressed in clinical and preclinical cohorts following ischaemic or haemorrhagic stroke. Further studies, employing larger populations with consistent methodologies, are required to validate the true clinical value of circulating microRNAs as biomarkers of ischaemic and haemorrhagic stroke.
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Affiliation(s)
- Josie L Fullerton
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Josephine M Thomas
- Division of Neuroscience & Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, & University of Manchester, Manchester, UK
| | - Laura Gonzalez-Trueba
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Cara Trivett
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Josie C van Kralingen
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Stuart M Allan
- Division of Neuroscience & Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, & University of Manchester, Manchester, UK
| | - Terence J Quinn
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Lorraine M Work
- Institute of Cardiovascular & Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Saleh Velez FG, Alvarado-Dyer R, Pinto CB, Ortiz García JG, Mchugh D, Lu J, Otlivanchik O, Flusty BL, Liberman AL, Prabhakaran S. Safer Stroke-Dx Instrument: Identifying Stroke Misdiagnosis in the Emergency Department. Circ Cardiovasc Qual Outcomes 2021; 14:e007758. [PMID: 34162221 DOI: 10.1161/circoutcomes.120.007758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis. METHODS We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ). RESULTS Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0-26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821-0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2-30.3) with similar sources of diagnostic error identified. CONCLUSIONS Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.
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Affiliation(s)
- Faddi G Saleh Velez
- Department of Neurology, University of Chicago Medical Center, University of Chicago, IL (F.G.S.V., R.A.-D., S.P.)
| | - Ronald Alvarado-Dyer
- Department of Neurology, University of Chicago Medical Center, University of Chicago, IL (F.G.S.V., R.A.-D., S.P.)
| | - Camila Bonin Pinto
- Institute of Psychology, University of Sao Paulo, Brazil (C.B.P.).,Department of Physiology, Northwestern University, Chicago, IL (C.B.P.)
| | - Jorge G Ortiz García
- Department of Neurology, University of Oklahoma Health Science Center (J.G.O.G.)
| | - Daryl Mchugh
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.M., O.O., B.L.F., A.L.L.)
| | - Jenny Lu
- Albert Einstein College of Medicine, Bronx, NY (J.L.)
| | - Oleg Otlivanchik
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.M., O.O., B.L.F., A.L.L.)
| | - Brent L Flusty
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.M., O.O., B.L.F., A.L.L.)
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.M., O.O., B.L.F., A.L.L.)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Medical Center, University of Chicago, IL (F.G.S.V., R.A.-D., S.P.)
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Wallace EJC, Liberman AL. Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes. Neuropsychiatr Dis Treat 2021; 17:1469-1480. [PMID: 34017173 PMCID: PMC8129915 DOI: 10.2147/ndt.s275750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/08/2021] [Indexed: 12/14/2022] Open
Abstract
Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.
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Affiliation(s)
- Emma J C Wallace
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
| | - Ava L Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
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