عنوان مقاله
اعتبار سنجی خارجی قاعده تصمیم گیری بالینی خونریزی ساب آراکنوئید اتاوا در بیماران با سردرد حاد
فهرست مطالب
چکیده
مقدمه
روش ها
نتایج
نتیجه گیری
بخشی از مقاله
روشها، اندازه گیری، جمع آوری داده ها و نتایج
ما به صورت الکترونیکی داده های زیر را از پرونده پزشکی الکترونیکی و پایگاه داده اداری در سیستم پرونده سلامت خلاصه برداری کردیم : متغیرهای جمعیت شناختی، عارضه اصلی، بررسی در ED از جمله CT سر ، CT آنژیوگرافی ، و/ یا پونکسیون کمری (LP)، علائم حیاتی اولیه، نمره درد، تشخیص نهایی، تمایلات ، و بازگشت به ED ظرف مدت 7 روز.
کلمات کلیدی:
External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache☆, ☆☆,★,★★ M. Fernanda Bellolio, MD, MS ⁎, Erik P. Hess, MD, MSc, Waqas I. Gilani, MD, Tyler J. VanDyck, BS, Stuart A. Ostby, BS, Jessica A. Schwarz, MD, Christine M. Lohse, MS, Alejandro A. Rabinstein, MD Department of Emergency Medicine, Department of Neurology, and Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA article info abstract Article history: Received 15 October 2014 Accepted 24 November 2014 Available online xxxx We aim to externally validate the Ottawa subarachnoid hemorrhage (OSAH) clinical decision rule. This rule identifies patients with acute nontraumatic headache who require further investigation. We conducted a medical record review of all patients presenting to the emergency department (ED) with headache from January 2011 to November 2013. Per the OSAH rule, patients with any of the following predictors require further investigation: age 40 years or older, neck pain, stiffness or limited flexion, loss of consciousness, onset during exertion, or thunderclap. The rule was applied following the OSAH rule criteria. Patients were followed up for repeat visits within 7 days of initial presentation. Data were electronically harvested from the electronic medical record and manually abstracted from individual patient charts using a standardized data abstraction form. Calibration between trained reviewers was performed periodically. A total of 5034 ED visits with acute headache were reviewed for eligibility. There were 1521 visits that met exclusion criteria, and 3059 had headache of gradual onset or time to maximal intensity greater than or equal to 1 hour. The rule was applied to 454 patients (9.0%). There were 9 cases of subarachnoid hemorrhage (SAH), yielding an incidence of 2.0% (95% confidence interval [CI], 1.0%-3.9%) in the eligible cohort. The sensitivity for SAH was 100% (95% CI, 62.9%-100%); specificity, 7.6% (95% CI, 5.4%-10.6%); positive predictive value, 2.1% (95% CI 1.0%-4.2%); and negative predictive value, 100% (95% CI, 87.4%-100%). The OSAH rule was 100% sensitive for SAH in the eligible cohort. However, its low specificity and applicability to only a minority of ED patients with headache (9%) reduce its potential impact on practice. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Headache is a common complaint in emergency departments (EDs) across the United States, accounting for up to 4% of ED visits [1,2]. Identifying the small number of patients with a life-threatening headache among the majority with benign primary headache (eg, migraine or tension) is an important and common problem. Failure to recognize a serious underlying cause of the headache can have potentially fatal consequences. A careful history and physical examination remain the most important elements of the assessment of the headache patient, enabling the clinician to determine the risk of a dangerous etiology and the need for additional workup [3,4]. Use of computed tomography (CT) to identify a potential serious underlying cause of nontraumatic headache has increased dramatically in the past 15 years [5]. The number of patients presenting to the ED with nontraumatic headache who underwent CT imaging increased from 13% to 31% over a 10-year period [3]. However, the incidence of subarachnoid hemorrhage (SAH) among those presenting with headache is relatively low and is estimated to be 0.5% to 6% [1,4,6,7]. A recently published clinical decision rule, the Ottawa SAH (OSAH) rule, seeks to identify the few cases of SAH among patients presenting with acute nontraumatic headache. The OSAH rule was 100% sensitive and 15% specific for detection of SAH among patients presenting to the ED with acute nontraumatic headache reaching maximum intensity within 1 hour and a normal neurologic examination [7]. Clinical decision rules require validation in diverse clinical settings before they should be broadly used [8,9]. In this investigation, we externally validate the OSAH rule to assess its classification performance in an independent patient population and to estimate the potential impact of implementing the rule in a US setting. American Journal of Emergency Medicine xxx (2014) xxx–xxx ☆ Previous presentation: The abstract of this study was presented at the Midwest SAEM meeting on September 11, 2014, Detroit. ☆☆ Grant or other financial support: We received funding through a nonprofit organization in Canada, the Andison Family Foundation. ★ Conflicts of interest: None of the authors have conflicts of interest to disclose. The authors have no financial or philosophical conflicts of interest with the decision rule and were not involved in the original development or validation. ★★ Ethics approval: This study was approved by the institutional review board at Mayo Clinic, and patients not consenting for medical records review for research were excluded in accordance with the Minnesota State Law. ⁎ Corresponding author at: Mayo Clinic, 200 First St SW, Rochester, MN 55905. Tel.: +1 507 255 6501; fax: +1 507 255 6592. E-mail address: Bellolio.Fernanda@mayo.edu (M.F. Bellolio). http://dx.doi.org/10.1016/j.ajem.2014.11.049 0735-6757/© 2014 Elsevier Inc. All rights reserved.
