急诊室多发性硬化症常被漏诊

圣迭戈(EGMN) ——纽约西奈山医学院的Stephen Krieger医生在第四次多发性硬化症合作会议上报告，在这家设有多发性硬化症(MS)中心的教学医院的急诊室中，接近40%的MS患者被漏诊，由此不难想见，专业力量更弱的较小医院的漏诊率会更高。这次会议由多发性硬化症治疗中心联盟和美国多发性硬化症治疗与研究委员会主办。

研究者回顾性分析了该院49例急诊科就诊患者的神经科症状评估情况，这49例患者均在之后被诊断为MS。其中几乎半数是因感觉症状就诊，其他患者是因视力变化、虚弱、平衡障碍、复视和眩晕就诊。

结果显示，仅有30例患者(61%)在急诊就诊或之后被收入院时诊断为MS或脱髓鞘疾病，其他19次急诊就诊(39%)均被漏诊。研究者强调这是一个很重要的结果，因为早期诊断和治疗可改善MS预后。在这些急诊就诊中，约有1/3的患者在6个月后仍未得到诊断，少数甚至在1年之后方被诊断为MS。

“这是值得我们特别关注的一部分患者，并且我们应深思该如何改变这种状况，”西奈山Corinne Goldsmith Dickinson MS中心的一位MS专家Krieger医生说。研究显示，在男性、中年和神经科症状模糊的患者中，延误诊断的风险似乎最大。但该研究纳入的患者数有限，无法得出有统计学意义的结果。此外，由ED收入院的患者较未被收入院患者可能更快得到诊断。

研究者总结认为，因急性神经科症状就诊于急诊室是诊断和治疗临床孤立综合征以及MS的一个重要机会，在尽快做出诊断方面仍有很大的改善余地。

这项研究由拜耳医药保健公司资助。Krieger医生披露自己担任阿索尔达治疗、拜耳医药保健、百健艾迪、EMD雪兰诺、健赞、诺华和Questcor公司的有偿顾问，并且接受了梯瓦神经医学提供的非CME服务费。

SAN DIEGO (EGMN) – An emergency department at an academic medical institution with a multiple sclerosis center missed diagnosing multiple sclerosis in nearly 40% of patients who were later diagnosed with the disease, calling into question what the rate of missed cases might be at smaller centers staffed by fewer specialists.

The retrospective study analyzed assessments for neurologic symptoms during 49 emergency department (ED) visits at the Mount Sinai School of Medicine in New York that were made by 49 people who were later diagnosed with MS. The researchers judged most of those presentations to be initial manifestations of the disease.

Just 30 of the visits (61%) resulted in a diagnosis of MS or demyelinating disease, either in the ED or on subsequent admission, Dr. Stephen Krieger said at the Fourth Cooperative Meeting on Multiple Sclerosis, which was sponsored by the Consortium of Multiple Sclerosis Centers and the America’s Committee for Treatment and Research in Multiple Sclerosis.

The diagnosis was missed in the remaining 19 (39%) visits, an important finding because early diagnosis and treatment leads to better MS outcomes. About a third of the patients involved in those visits still hadn’t been diagnosed 6 months later. It took more than a year to diagnose a few of them. “Those are the patients we have to look at to see what could have been done differently,” said senior investigator Dr. Krieger, an MS specialist at the Corinne Goldsmith Dickinson Center for MS at Mount Sinai.

The risk of delayed diagnosis seemed to be greatest for men, the middle aged, and those with vague neurologic symptoms – all of whom are nontraditional MS patients – but the study didn’t have enough patients to demonstrate those findings statistically. Patients who were admitted from the ED, however, were more likely to be diagnosed quickly than were nonadmitted patients.

“Emergency department presentations for acute neurologic symptoms are an important opportunity to diagnose and treat clinically isolated syndrome and MS. There’s room to make that diagnosis more rapidly,” Dr. Krieger said.

Even though the project was a single-center study, Dr. Krieger noted that Mount Sinai is an academic center with a busy neurology department, a neurology residency, and a multiple sclerosis center. In short, “we are sort of a best case scenario. A lot of other emergency departments without as much access to MS specialists may” have a harder time making a prompt diagnosis, he said.

His team plans to analyze demographic data and symptom presentations to develop robust predictive factors for delayed MS diagnoses.

Although the findings are concerning, Dr. Lael Stone, an MS specialist at the Cleveland Clinic, noted that the situation has improved in recent years. “It used to be that [the elapsed time between] first symptoms [and] diagnosis was on the order of 9 years. That has gone down dramatically,” she said.

Even so, “we have a ways to go in terms of picking up MS in the [emergency department], which we should be able to do,” she said at the meeting.

Vague and confusing neurologic symptoms remain a problem. The demyelinating disease neuromyelitis optica, for example, can present with month-long intractable vomiting, years before the condition is diagnosed.

“The intractable vomiting goes to the GI doctor or to the [ED]. I doubt that the [ED or GI specialist] thinks this might be neuromyelitis optica,” she said.

Among the 49 ED visits for neurologic symptoms at Mount Sinai, almost half were for sensory symptoms; the remainder were for vision changes, weakness, balance problems, diplopia, and vertigo.

Bayer Healthcare Pharmaceuticals funded for the study. Dr. Krieger said he is a paid consultant for Acorda Therapeutics, Bayer Healthcare Pharmaceuticals, Biogen Idec, EMD Serono, Genzyme, Novartis, and Questcor. He receives fees from Teva Neuroscience for non-CME services. Dr. Stone said she has no relevant disclosures.