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

项目摘要/摘要：一线医生需要可靠的解决方案来区分良性和恶性 头晕的原因目前的区别策略要么依赖于临床教条，要么依赖于大脑计算机化 断层扫描，但这些策略有重大缺陷，并与误诊有关。在头晕中 介绍，急性前庭综合征-一种常见的急性发作性头晕-是 医生的决定是最重要的。一方面，最常见的原因是 急性前庭综合征是完全良性的外周前庭病毒综合征（即，所谓的前庭 神经炎或尿道炎），但另一方面，病因可能是危及生命的中风。无既往研究 准确估计基本信息，例如急性前庭综合征中卒中病因的比例 介绍。此外，以前没有研究使用严格的方法来估计中风的风险， 个别患者。头晕表现不同于其他常见的诊断困境（例如，胸部 疼痛和头痛表现），因为没有实验室、电生理或神经影像学检查是有效的 和实用性。虽然磁共振成像（MRI）是一种敏感的中风测试，但它不是一种有效的方法。 在真实的世界紧急情况设置中用作警报器的实际测试。中风风险评分-计算 从常规收集的临床信息-可能是一个实用的方法。另一个潜在的 可能是“头部推力测试”，一种简单的前庭系统床边测试。然而，中风风险评分 没有在这种独特的介绍和头部推力测试没有经过严格的研究， 确定其在这一重要临床环境中的操作特性。在这个R18应用程序中，我们的目标是 优化急性头晕医疗保健的价值和安全性的初步步骤。一名代表 将招募样本，所有受试者将接受对MRI结果设盲的标准化临床评价。 使用磁共振弥散加权序列作为卒中病因学的金标准测试，我们计划开发一种 评估急性前庭综合征患者中风风险的统计模型。型号- 基于临床测量和头部推力测试的预测。该模型将用于 评估目标患者人群中卒中的患病率以及头部推力试验作为 有和没有临床协变量的风险预测因子。使用特异性灵敏度和特异性折衷参数， 我们将根据该模型制定决策规则。将进行内部模型验证，以获得 无偏估计的经营特点。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。该示范项目将奠定 为未来的多中心验证和实施研究奠定基础，最终可以改善 护理和病人安全的价值，同时也促进护理过程的适当使用， 不必要的支出。

Project summary/Abstract: 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.