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邪恶 头晕的原因。目前的歧视策略要么依赖于临床教条，要么依赖于大脑计算机 断层扫描，但这些策略有重大缺陷，并与误诊有关。在眩晕中 急性前庭综合征是一种常见的急性发作性眩晕。 在医生的决定最关键的地方发表演讲。一方面，最常见的原因是 急性前庭综合征是一种完全良性的外周前庭病毒综合征(即所谓的前庭 神经炎或迷路炎)，但另一方面，原因可能是危及生命的中风。没有先前的研究 准确估计急性前庭综合征中中风病因的比例等基本信息 演示文稿。此外，以前没有研究使用严格的方法来估计中风的风险 个别病人。头晕的表现不同于其他常见的诊断难题(例如，胸部 疼痛和头痛的表现)，因为没有实验室、电生理或神经成像测试是有效的 和实用的鉴别者。虽然磁共振成像(MRI)是一种对中风敏感的测试，但它不是一种 在现实世界的紧急情况下用作鉴别器的实用测试。中风风险得分-计算得出 从常规收集的临床信息中-可能是一个实用的鉴别器。另一个潜在的鉴别者 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，中风风险评分具有 没有在这种独特的表现中开发，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运行特点。在此R18应用程序中，我们的目标是 在急性头晕症状中优化医疗保健价值和安全性的初步步骤。一位代表 样本将被招募，所有受试者将接受标准化的临床评估，对MRI结果视而不见。 使用磁共振弥散加权序列作为中风病因的金标准测试，我们计划开发一种 评估急性前庭综合征患者卒中风险的统计模型。模型- 基于预测将基于临床测量和头部推力测试。该模型将用于 评估卒中在目标患者人群中的患病率以及推头试验作为一种 有无临床协变量的风险预测因子。使用特定的灵敏度和特异度折衷参数， 我们将根据该模型制定决策规则。将执行内部模型验证以获得 对经营特征的公正估计。还将测量头部推力测试的可靠性。 这将有助于在未来的样本中估计模型的性能。这一示范项目将为 为未来多中心验证和实施研究奠定基础，最终可能改善 护理的价值和病人的安全，同时也促进适当使用护理过程和减少 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.