The effects of functional action-observation training on gait function in patients with post-stroke hemiparesis: A randomized controlled trial

Useless. Weasel words like 'likely' mean nothing to stroke survivors. 'Do this, get these results.', is what is needed. 'Are you that willfully blind to survivor needs?' 

The effects of functional action-observation training on gait function in patients with post-stroke hemiparesis: A randomized controlled trial

Technology and Health Care , Volume 27(2) , Pgs. 159-165.

NARIC Accession Number: J81696.  What's this?
ISSN: 0928-7329.
Author(s): Oh, Seung-Jun; Lee, Je-Hyeok; Kim, Do-Hyun.
Publication Year: 2019.
Number of Pages: 17.
Abstract: Study investigated the effects of functional action observation (FAO) training on gait ability in patients with post-stroke hemiparesis. FAO is defined as a training to observe an objective movement, such as bringing water from a refrigerator, distinct from general action observation (GAO). It has positive effects on the motor function recovery of stroke patients. In addition, FAO is likely to activate the corticospinal tract and is likely to increase the potential ability of a functional task. Thirty-five patients with hemiparesis caused by stroke participated in this study. All subjects had suffered from stroke for more than 6 months. Subjects received either FAO or GAO training for 30 minutes each time, five times per week, for four weeks. The GAITRite was used to measure walking velocities and spatiotemporal variables. The Functional Gait Assessment (FGA) was used to assess gait ability. The independent t-test was used to analyze whether there were significant differences of all dependent variables between groups. After four weeks of training, the step length, stride length, cadence, velocity, and FGA score in FAO group were statistically different from the GAO group. The results of this study suggest that FAO is an effective and easy method for improvement of gait ability in chronic stroke patients.
Descriptor Terms: AMBULATION, AUDIOVISUAL MATERIALS, HEMIPLEGIA, INTERVENTION, MOBILITY IMPAIRMENTS, OUTCOMES, REHABILITATION TECHNOLOGY, STROKE, THERAPEUTIC TRAINING.


Can this document be ordered through NARIC's document delivery service*?: Y.
Get this Document: https://content.iospress.com/articles/technology-and-health-care/thc181388.

Citation: Oh, Seung-Jun, Lee, Je-Hyeok, Kim, Do-Hyun. (2019). The effects of functional action-observation training on gait function in patients with post-stroke hemiparesis: A randomized controlled trial.  Technology and Health Care , 27(2), Pgs. 159-165. Retrieved 10/22/2019, from REHABDATA database.
 

New recommendations for stroke systems of care to improve patient outcomes

Are you that goddamned willfully blind that you can't see that systems of 'care' are not what is needed? We need fucking stroke rehab protocols that provide results. 100% RECOVERY.  THIS is why I call them fucking failures of stroke associations, yep the AHA is really the ASA.

New recommendations for stroke systems of care to improve patient outcomes

DALLAS, May 20, 2019 - Improvements in stroke systems of care are necessary to ensure scientific advances in the treatment and care of stroke patients improve patient outcomes, according to a policy statement published today by the American Stroke Association, a division of the American Heart Association, in the journal Stroke.
The policy statement, released during National Emergency Medical Services (EMS) Week, comes as stroke systems of care have seen vast improvements in availability of endovascular therapy, neurocritical care and stroke center certification over the past decade. In addition, innovations such as telestroke and mobile stroke units have increased access for stroke patients to alteplase, a lifesaving, clot-busting drug.
"We have seen monumental advancements in acute stroke care over the past 14 years, and our concept of a comprehensive stroke system of care has evolved as a result,"(I see very little advancement, since I look at care as lazy and counterproductive.) said Opeolu Adeoye, M.D., the chair of the writing group for the statement and associate professor of emergency medicine and neurosurgery at the University of Cincinnati. "These recommendations reflect how far we have progressed and what still needs to be accomplished to maximize patient outcomes in acute stroke care."
The statement recommends that when more than one intravenous alteplase-capable hospital is within reach, Emergency Medical Services (EMS) should consider additional travel time of up to 15 minutes to reach a hospital capable of performing endovascular thrombectomy (also called stent retrievers) for patients suspected of having a severe stroke. Both intravenous alteplase, a clot-dissolving therapy, and endovascular thrombectomy, a procedure to remove a clot mechanically, must be administered quickly to be effective, but not every hospital is able to deliver these services.
"While it is vitally important for patients suspected of having a large vessel blockage to get to the hospital quickly, getting to the right hospital is equally important," Adeoye said.
The statement also addresses disparities in care among racial and ethnic minorities, who are less likely to use EMS and have the lowest awareness of the causes and symptoms of stroke. Among Hispanic and black populations in particular, lack of knowledge of the risk factors and symptoms of stroke can hamper timely stroke care.
In response, the statement recommends that public health leaders and medical professionals implement public education programs focused on stroke systems and the need to seek emergency care by calling 9-1-1 in response to stroke symptoms.
The statement also includes the following recommendations:
Education: Stroke systems of care should support local and regional public education initiatives to increase awareness of stroke symptoms with an emphasis on at-risk populations.
Triage: EMS leaders, governmental agencies, medical authorities and local experts should work together to adopt consistent, standardized triage protocols to rapidly identify patients with a known or suspected stroke.(Triage is just your lazy way of saying; We have nothing for certain cases. You need to have the perfect stroke for us to be able to treat you.)
Secondary Prevention: Certified stroke centers should help stroke survivors reduce the of risk of subsequent strokes, consistent with the national guidelines for secondary prevention.
Rehabilitation and Support: A stroke system should provide comprehensive post-stroke care (Not results) including ongoing primary care and specialized stroke services such as physical, occupational, speech or other therapies on discharge.
Federal and State Policies: Policies should be enacted to standardize the organization of stroke care, lower barriers to seeking emergency care for stroke, ensure stroke patients receive care at appropriate hospitals in a timely manner, and facilitate access to secondary prevention and rehabilitation and recovery resources after stroke.
A stroke occurs every 40 seconds in the U.S., and someone dies of a stroke every four minutes. An estimated 7.2 million Americans aged 20 years or older have had a stroke, and approximately 800,000 people in the U.S. have a new or recurrent stroke each year.
Optimized stroke systems of care that span health care delivery from primordial prevention to rehabilitation and recovery help to ensure patients, caregivers and providers have the tools needed for prevention, treatment and recovery.
Implementation of the American Heart Association's Get With The Guidelines - Stroke at U.S. hospitals has been associated with an 8 percent reduction in mortality at one year and improved functional outcome at hospital discharge.

Credit: 

American Heart Association

Why innovation isn’t the key for treating stroke

You blithering idiot. No wonder stroke never gets anywhere when VPs like this are being willfully blind to all the fucking problems in stroke. tPA administration is not the answer, it fails to completely resolve the stroke 88% of the time. Do you NOT know that?

Why innovation isn’t the key for treating stroke

January 3, 2018 By Danielle Kirsh Leave a Comment

Stacy Pugh, VP and general manager of Medtronic’s neurovascular unit

Technology and innovation are not the most important things we can do for stroke, according to Stacey Pugh, VP and general manager of the neurovascular unit at Medtronic.
The most important thing that could happen for stroke is passing proper legislation about taking patients in emergency situations to comprehensive stroke centers for proper treatment, Pugh explained during her keynote discussion at DeviceTalks West last month.
Technology has changed, but systems of care have not.
“The most important thing we can do today in stroke unfortunately isn’t innovation. It’s legislation,” Pugh said.
A stroke occurs when blood flow to an area of the brain is cut off, resulting in a deprivation of oxygen to brain cells, which then start to die. When brain cells die during a stroke, the abilities of that area of the brain are lost. Nearly 800,000 people a year experience a new or recurrent stroke in the U.S., according to the National Stroke Association.
Medtronic presently has a small device on the market – the Solitaire revascularization device – that reduces stroke mortality. It goes through the groin and into the brain – integrating into a clot and pulling the clot out of a large vessel occlusion. But only about 10–15% of people in the U.S. who are eligible to receive the therapy get it.
“There’s a couple of reasons for that,” Pugh said. “Part of it is stroke systems of care. The underlying medical system hasn’t evolved with the technology.”
The American Heart Association and the American Stroke Association help designate primary and comprehensive stroke care centers. The Solitaire is generally only available at comprehensive stroke care centers; primary centers are limited to doing a CT scan to locate a bleed or blockage and administering the clot-busting drug tPA, according to Pugh. Without legislation, an ambulance can drive past several comprehensive stroke centers that are capable of performing the intervention with the Solitaire before arriving at a primary care center – even if the stroker sufferer is outside the time window in which tPA is effective.
“There’s nothing in 30 states that says you have to be transferred to a comprehensive center,” Pugh said. “If you have a stroke in Baylor, Texas, the law actually requires that they take you to a primary stroke care center.”
Go to a primary center before a comprehensive center, and data shows that it’s a 90-minute delay on average, according to Pugh.
“Ninety times 1.9 million [dead brain cells a minute] – it’s not a pretty sight,” Pugh said. “So, for every 30 minutes you’re delayed from getting intervention, you decrease the likelihood of a good outcome – not zero disability but what we would consider reasonable functional independence – by 10%.”
The present system of transport for stroke patients reflects a time when TPA was the only way to treat stroke – and the idea was to get stroke sufferers access to the drug as quickly as possible, Pugh said.  Before there was device intervention, comprehensive and primary centers were not much different from each other. They could both administer tPA and determine if a patient needed a higher level of care – for bleeding in the brain, for example – and transfer the patient as needed.
“We’ve been able to show in that study that you could drive a patient an additional 20 miles and take them to a comprehensive stroke center, and they still get tPA faster. So the only reason to stop in the primary center was to get a patient tPA faster, but you can get it faster going to the comprehensive center, even with an additional 20 miles, because speed is everything in these centers,” Pugh said.
The odds of getting treatment are better if a stroke patient is a trauma patient as well, according to Pugh. There is a system in the U.S. that states if a patient is having a massive injury, they are guaranteed a direct route of care. There are designated trauma centers that are well-known. That’s not the case with stroke. There is no designated pathway for getting stroke treatment.
“There’s a situation today where, it sounds horrible, but I tell people that if your loved one is having a stroke, put them on bike in the middle of the street and push them over. Because if you’re a trauma patient, you’re guaranteed to get treatment within the golden hour,” Pugh said.

2 decades of stroke

Willfully blind to all the fucking failures in stroke, and still focused on prevention rather than having the doctors/researchers getting survivors to 100% recovery. Yes that is a BHAG(Big Hairy Audacious Goal) ,  but leaders don't shy away from difficulty. 
https://www.healio.com/cardiology/stroke/news/print/cardiology-today/%7Bae908ac4-1f60-4cad-93dc-390afe4d25c0%7D/2-decades-of-stroke?utm_source=selligent&

A Cardiology Today Editorial Board member discusses progress in stroke prevention and treatment.

Cardiology Today, June 2017

Editor’s Note: Cardiology Today is celebrating its 20th anniversary in 2017. We are reaching out to experts in cardiology for their take on changes in CV medicine since the publication launched in 1997. In this issue, Larry B. Goldstein, MD, FAAN, FANA, FAHA, focuses on stroke.

It appears the prevalence of stroke is essentially unchanged from 20 years ago. These data are very difficult to obtain because the United States does not have an active stroke surveillance system. According to the National Health Interview Survey, the prevalence of stroke in the U.S. was 2.3% in 1997; based on the Behavioral Risk Factor Surveillance System, the prevalence increased to 2.7% in 2014 — the latest data available. This may, to some extent, be related to the aging of the population.

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• Prevalence of wake-up strokes found in large population

On a more positive note, between 2004 and 2013, there was a 41% reduction in stroke mortality in the U.S., largely related to better prevention. The stroke mortality rates between 2013 and 2015, however, showed an increase, particularly among younger adults. The reasons are not entirely clear, but may in part be related to increased prevalence of obesity and diabetes.

It does not appear there has been a major shift in knowledge related to stroke risk factors. A study published in 1999 found that only 50% of patients interviewed named hypertension as a stroke risk factor, while 37% named smoking, 27% named obesity, 22% named poor diet, and 10% named lack of exercise. A study published in 2006 found that only 43% of patients interviewed named hypertension, 39% named smoking, 34% named obesity, 14% named poor diet and 20% named lack of exercise. In addition, there are major areas for improvement of CV and brain health. The latest data indicate that 16% of individuals older than 50 years smoke compared with 24% of those aged 20 to 49 years; 40% older than 50 years are obese, 55% do not get adequate exercise, 70% do not follow recommendations for a healthy diet and 25% have poorly controlled hypertension. There is increasing recognition of the importance of lifestyle as a means of preventing a first stroke — those who follow a healthy lifestyle are 80% less likely to have a stroke compared with those who don’t. Effecting lifestyle change, however, is not trivial.

There have also been advances in medical therapy for stroke prevention in appropriate populations. These include the use of platelet anti-aggregates, the more widespread use of statins and the availability of the non-vitamin K antagonist oral anticoagulants as an alternative to warfarin to prevent stroke and systemic embolization in high-risk patients with atrial fibrillation.

Larry B. Goldstein

Over the past 2 decades, there also has been a revolution in acute stroke care, initiated by the advent of treatment with IV tissue plasminogen activator beginning in 1995.(Yet, still a complete fucking failure(12% full success rate) because you are doing nothing to address the 5 causes of the neuronal cascade of death.)This led to the development of stroke systems of care, organizing pre-hospital care bring patients as quickly as possible to designated primary or comprehensive stroke centers, including care in stroke units. More recently, it was shown that selected patients with large vessel occlusions benefit from endovascular clot retrieval. I consider all of these things to be most significant advances related to stroke in the past 20 years.

– Larry B. Goldstein, MD, FAAN, FANA, FAHA

Cardiology Today Editorial Board Member

University of Kentucky

DAWN study increases window for treatment of stroke patients

And yet they are still doing nothing to stop all the dead and dying neurons because of the neuronal cascade of death by these 5 causes in the first week. Is the whole stroke medical world that willfully blind and stupid? Yes it is. 
https://www.news-medical.net/news/20171127/DAWN-study-increases-window-for-treatment-of-stroke-patients.aspx

• Download PDF Copy

November 27, 2017

Treating stroke has long been governed by the clock. If it has been less than three hours since the onset of symptoms, the clot-busting drug t-PA will likely work. If it has been four and a half hours, some selected patients might benefit. However, if it has been more than six hours, treatment options have been few.

Now that conventional wisdom has been turned on its head. The final results of the DAWN study, of which University Hospitals Cleveland Medical Center was a major participant, are in, and have been published in The New England Journal of Medicine. They show that selected patients(So you better have the correct stroke) with stroke caused by a blood clot can be effectively treated with a procedure to remove the clot mechanically – and that this can be done up to 24 hours after the onset of symptoms.

"This is incredible," said Cathy Sila, MD, Director of UH's Comprehensive Stroke Center and principal investigator of the DAWN study at the UH site. "Almost half of the patients receiving the thrombectomy therapy had a good outcome at 90 days after treatment – defined as the patients being independent in activities of daily living – as opposed to only 13.1 percent of the patients treated medically or with clot-busting drugs alone. This 35 percent difference may be higher than any level of benefit from any stroke trial."

"This is pretty extraordinary and will fundamentally change the way stroke is treated around the world," said Michael De Georgia, MD, Director of UH's Neurocritical Care Center. "What this study shows is that the patient's own physiological clock matters more than what the actual clock on the wall says. That is, if on brain imaging there still appears to be a significant degree of salvageable tissue, then it's still beneficial to take the patient to the cath lab and open the blocked artery even if it's 24 hours after symptom onset."

The DAWN trial compared standard medical therapy with mechanical thrombectomy using the Trevo stent retriever. It concluded after 31 months when it became clear that thrombectomy was the superior treatment for all different subgroups of stroke patients – those waking up with a stroke, those with witnessed symptoms and those with unwitnessed symptoms.

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UH was one of just two sites in Ohio conducting the DAWN trial and the only one in Northeast Ohio.

Anthony Furlan, MD, Chairman of the Department of Neurology at UH and Case Western Reserve University School of Medicine, was on the DAWN study's steering committee and helped write the protocol.

"These results provide physicians who treat stroke with evidence of the benefits of thrombectomy even when administered out as far as 24 hours, and should help to make decision clearer as to which patients to treat," he said. "These positive outcome of the DAWN trial represent a major change in patient selection for endovascular therapy for stroke. DAWN provides an opportunity for UH to treat more patients, but also poses challenges for timely patient diagnosis and transport as currently endovascular therapy can only be done at UH Cleveland Medical Center."

Dr. Sila said that Northeast Ohio sees about 18,000 strokes per year. Stroke survivors commonly experience devastating disabilities and loss of independence due to impaired movement, paralysis, loss of speech and memory.

The DAWN study was supported by Stryker, which produces the Trevo Retriever, a tiny stent-shaped medical device that is attached to a thin wire. The retriever is designed to ensnare the blood clot to remove it from a blood vessel.

UH is working with Case Western Reserve University to develop the Cleveland Brain Health Initiative, linking this kind of leading-edge neuroscience work from CWRU, UH, Cleveland Clinic, MetroHealth Medical Center and the Louis Stokes Cleveland VA Medical Center to advance progress therapy and treatment of devastating neurological diseases.

Source:

http://news.uhhospitals.org/news-releases/uh-is-part-of-landmark-dawn-study-expanding-treatment-window-for-strokes.htm

Want to change the world? Be helpful.

A gapingvoid art print. In your stroke world it means helping your doctor, therapists and stroke hospital see how fucking bad they are at getting you to 100% recovery. Nothing is worse than supposedly smart people being willfully blind to their failures.  Getting you walking is not a success, getting you running might be a success depending on your marathon or triathlon ability.

Stroke Death Progress Slows in U.S. Likely due to country's struggle with risk factors, CDC says

The whole problem here is the single-minded focus on prevention. I'm sure by focusing on stopping the neuronal cascade of death by these 5 causes in the first week the 30-day death rate could  be dropped substantially. But the stroke medical world is willfully blinded by the status quo of prevention only. The cures to the  neuronal cascade of death are  BHAGs(Big Hairy Audacious Goals)
 that no one seems to be willing to undertake.  
https://www.medpagetoday.com/Cardiology/Strokes/67732?

• by Nicole Lou, Reporter, MedPage Today/CRTonline.org September 06, 2017

Stroke deaths in the U.S. may be on the upswing again after a decline in recent decades, according to a CDC Vital Signs report.
Stroke mortality fell each year from 2000 to 2013, from just under 120 to 70 per 100,000. But after that, stroke deaths climbed back up by 4% every year, reaching 75 per 100,000 in 2015, according to Robert Merritt, MA, a health scientist at the CDC.
"My explanation would be a continued struggle in this country with risk factors," he said during a press telebriefing, citing hypertension, diabetes, and physical inactivity among other examples. Two more reasons for the comeback of stroke deaths: the difficulty of recognizing stroke symptoms and the reluctance to seek care, he added.
"I think the systemic changes are being made -- we've seen the advances in tPA, the clot busting drugs. All those things are very good. But if the risk factors remain high, and people don't call 911 when they have a stroke, it's going to offset all those good things that are going on," Merritt warned.
The decline in stroke death slowed down in 38 states over the 2000-2015 period. In fact, most Southern and Southwestern states showed a renewed uptick in these deaths. The Midwest, on the other hand, saw continued declines in stroke deaths.
Certain subpopulations also appeared to be increasingly vulnerable to fatal strokes during this time, namely Hispanics and African Americans, who remain at highest risk for stroke death, researchers said.
"This is an important wake-up call. The majority of strokes we see are avoidable and we know how to prevent them," said CDC Director Brenda Fitzgerald, MD, during the briefing.
Health systems have an important role in finding patients with undiagnosed or unmanaged stroke risk factors, in working with emergency medical services to identify strokes and get patients transported to the hospital quickly, and in implementing systems of care that encompass stroke care from hospital admission to discharge and recovery.
For their part, healthcare professionals can identify and treat hypertension, obesity, diabetes, high cholesterol, smoking and other risk factors, Merritt said.

Improving Stroke Diagnosis Accuracy: An Interview With David Newman-Toker, MD, PhD

How often does your stroke hospital misdiagnose stroke? If they don't even know that they should be closed. Not measuring missed diagnosis is actually a feature of stroke hospitals. That way they can be willfully blind, See no evil, hear no evil, speak/do no evil.

Improving Stroke Diagnosis Accuracy: An Interview With David Newman-Toker, MD, PhD

In the United States, more than 12 million people receive an inaccurate medical diagnosis annually, and nearly every individual is likely to be misdiagnosed at least once.^1,2 It is estimated that at least 40,000 to 80,000 deaths per year result from such errors, and 47% of hospital misdiagnoses lead to serious disability.^3,4
More than half of malpractice cases pertaining to emergency departments (EDs) stem from diagnostic errors, and some findings indicate these may be disproportionately high for neurologic conditions, and especially stroke.⁵ Other research shows that misdiagnosis leads to death significantly more often with cerebrovascular events compared with myocardial infarction (45% vs 1%; P <.001).⁶

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Although multiple studies have found elevated rates of stroke misdiagnosis, including a study from 2014 demonstrating that up to 12.7% of hospital stroke admissions were misdiagnosed initially, the precise numbers are unclear because of wide variation in reported rates.⁷ More accurate "estimates would help clarify the burden of harms from misdiagnosis and could help identify subgroups for which misdiagnosis-reduction interventions should be sought," wrote Alexander Andrea Tarnutzer, MD, from the University Hospital Zurich, Switzerland, and colleagues in a new article published in Neurology.⁸
To that end, they conducted a meta-analysis of 23 studies on diagnostic accuracy pertaining to ischemic stroke, transient ischemic attack, or subarachnoid hemorrhage, with a total of 15,721 patients. Their findings show that nearly 8.7% of cerebrovascular events are initially misdiagnosed in the ED, and rates are substantially higher for patients with symptoms that are:

• Milder (subarachnoid hemorrhage with normal vs abnormal mental state; false-negative rate, 23.8% vs 4.2%; odds ratio [OR], 7.03; 95% CI, 4.80-10.31),
• Nonspecific (dizziness vs motor findings; false-negative rate, 39.4% vs 4.4%; OR, 14.22; 95% CI, 9.76-20.74), or
• Transient (transient ischemic attack vs ischemic stroke; false discovery rate, 59.7% vs 11.7%; OR, 11.21; 95% CI, 6.66-18.89).

To learn more about these results and how physicians might help reduce the frequency of such misdiagnoses, Neurology Advisor spoke with the study's senior investigator, David E. Newman-Toker, MD, PhD, professor of neurology, ophthalmology, and otolaryngology at Johns Hopkins University School of Medicine in Baltimore, Maryland; director of the Division of Neuro-Visual & Vestibular Disorders; and director of the Armstrong Institute Center for Diagnostic Excellence.
Neurology Advisor: What are the likely reasons for your finding that nearly 9% of patients with stroke admitted to the ED are misdiagnosed?
Dr Newman-Toker: The patients most likely to be misdiagnosed are those with atypical stroke symptoms. Most often these are common, nonlateralizing symptoms such as dizziness, vertigo, headaches, confusion, or decreased level of consciousness. Roughly 95% of patients presenting with such symptoms to acute care settings do not have strokes as a cause, so finding these strokes requires the ability to separate them from more common causes with high accuracy.
False-negative neuroimaging is more common than often imagined: computed tomography misses >80%, and magnetic resonance imaging misses 10-20% of acute ischemic strokes in the first 48 hours, especially with posterior fossa infarctions. Many of the bedside techniques to differentiate dangerous from benign causes (eg, vestibular neuritis vs cerebellar stroke) rely on tests unfamiliar to most emergency physicians and many neurologists, such as the head impulse test of vestibulo-ocular reflex function as part of the HINTS (Head-Impulse-Nystagmus-Test-of-Skew) bedside test battery.
Neurology Advisor: What is the potential effect of these inaccurate diagnoses?
Dr Newman-Toker: Patients can suffer harms from delayed or missed diagnosis through missed opportunities for acute stroke treatments such as thrombolysis, critical care management of delayed stroke complications, or early secondary stroke prevention. As a result, some patients are left dead or disabled. Disproportionately, these harms affect women, minorities, and especially younger patients. Patients aged 18-45 years are 7-fold more likely to be missed than those older than 75 years. One 18-year-old patient I know, for example, is still trying to recover from locked-in syndrome after his initial presenting symptoms of vertigo and vomiting from vertebral artery dissection were misattributed to recreational drug use.
Neurology Advisor: What can neurologists do to improve stroke assessment and avoid misdiagnosis?
Dr Newman-Toker: Most patients with stroke are never seen by a neurologist, so diagnosis relies largely on the neurologic diagnostic skills of frontline care providers. This means neurologists need to engage their emergency medicine colleagues, working together to identify protocols and pathways for when to trigger appropriate neurological consultation or initiate acute stroke therapies. It also means neurologists must play a critical role in directly educating frontline physicians and providing feedback when errors occur.
Neurology Advisor: What should be the next steps in terms of research in this area?
Dr Newman-Toker: Surprising as it may be, there is no systematic monitoring of diagnostic accuracy or missed stroke. The critical next step is to begin operationally monitoring our diagnostic performance in differentiating strokes from stroke mimics. This will facilitate further studies to identify causes, develop and implement systems solutions, and monitor impact of these interventions.