Solutions for Vertigo presentations in the Emergency Department (SOLVE) Project

急诊科眩晕演示解决方案 (SOLVE) 项目

• 批准号: 8098677
• 负责人: Kevin Anthony Kerber
• 金额: $ 34.45万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-30 至 2013-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8098677
• 关键词: Solutions; Vertigo; presentations; Emergency; Department

DESCRIPTION (provided by applicant): Frontline physicians need reliable solutions to discriminate benign from sinister causes of dizziness. Current strategies to discriminate rely on either clinical dogma or brain computerized tomography scans, but these strategies have major flaws and are linked to misdiagnosis. Among dizziness presentations, the acute vestibular syndrome - a common category of acute-onset dizziness - is the presentation where physician decisions are the most crucial. On the one hand, the most common cause of the acute vestibular syndrome is an entirely benign peripheral vestibular viral syndrome (i.e., so called vestibular neuritis or labyrinthitis), but on the other hand the cause may be a life threatening stroke. No previous study accurately estimates basic information such as the proportion of stroke etiology in acute vestibular syndrome presentations. In addition, no previous study uses rigorous methodology to estimate the risk of stroke in an individual patient. Dizziness presentations are different from other common diagnostic dilemmas (e.g., chest pain and headache presentations) because no laboratory, electrophysiological, or neuro-imaging test is a valid and practical discriminator. Though magnetic resonance imaging (MRI) is a sensitive test for stroke, it is not a practical test to use as a discriminator in the real world emergency settings. A stroke risk score - calculated from routinely collected clinical information - may be a practical discriminator. Another potential discriminator may be the 'head thrust test,' a simple bedside test of the vestibular system. However, a stroke risk score has not been developed in this unique presentation and the head thrust test has not undergone rigorous study to determine its operating characteristics in this important clinical setting. In this R18 application, we aim to take the initial steps to optimizing value and safety of health care in acute dizziness presentations. A representative sample will be recruited and all subjects will undergo a standardized clinical evaluation blinded to MRI results. Using MRI with diffusion weighted sequences as a gold standard test for stroke etiology, we plan to develop a statistical model assessing the risk of stroke in patients presenting with the acute vestibular syndrome. Model based predictions will be based on clinical measurements and the head thrust test. The model will be used to assess the prevalence of stroke in the target patient population and the significance of the head thrust test as a risk predictor with and without clinical covariates. Using specific sensitivity and specificity tradeoff parameters, we will formulate a decision rule based on the model. Internal model validation will be performed to obtain unbiased estimates of operating characteristics. The reliability of the head thrust test will also be measured. This will help estimate model performance in future samples. This demonstration project will lay the groundwork for future multi-center validation and implementation studies that could ultimately improve the value of care and patient safety, while also fostering the appropriate use of processes of care and reducing unnecessary expenditures.

描述（由申请人提供）：一线医生需要可靠的解决方案来区分头晕的良性和恶性原因。目前的区分策略依赖于临床教条或大脑计算机断层扫描，但这些策略有重大缺陷，并与误诊有关。在头晕表现中，急性前庭综合征--一种常见的急性发作性头晕--是医生决定最关键的表现。一方面，急性前庭综合征的最常见原因是完全良性的外周前庭病毒综合征（即，所谓的前庭神经炎或前庭炎），但另一方面，病因可能是危及生命的中风。没有以前的研究准确估计基本信息，如中风病因在急性前庭综合征表现的比例。此外，以前没有研究使用严格的方法来估计个体患者的中风风险。头晕表现不同于其他常见的诊断困境（例如，胸痛和头痛表现），因为没有实验室、电生理或神经成像测试是有效和实用的诊断。虽然磁共振成像（MRI）是一种敏感的中风测试，它不是一个实用的测试，作为一个在真实的世界紧急设置的检查。根据常规收集的临床信息计算的中风风险评分可能是一种实用的方法。另一个潜在的测试可能是“头部推力测试”，这是一种简单的前庭系统床边测试。然而，中风风险评分尚未在这种独特的表现和头部推力测试还没有经过严格的研究，以确定其在这一重要的临床设置的操作特性。在这项R18申请中，我们的目标是采取初步措施，以优化急性头晕表现的医疗保健价值和安全性。将招募代表性样本，所有受试者将接受对MRI结果设盲的标准化临床评价。 我们计划使用磁共振弥散加权序列作为卒中病因学的金标准测试，建立一个统计模型，评估急性前庭综合征患者的卒中风险。基于模型的预测将基于临床测量和头部推力测试。该模型将用于评估目标患者人群中卒中的患病率，以及在有和无临床协变量的情况下，头部推力试验作为风险预测因子的显著性。使用特定的敏感性和特异性权衡参数，我们将制定一个决策规则的基础上的模型。将进行内部模型验证，以获得操作特征的无偏估计。还将测量头部推力试验的可靠性。这将有助于估计模型在未来样本中的性能。该示范项目将为未来的多中心验证和实施研究奠定基础，这些研究最终可以提高护理价值和患者安全，同时还可以促进护理过程的适当使用并减少不必要的支出。