Developing an implementation intervention for managing acute vertigo in the emergency department

BACKGROUND

There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science.

METHODS

A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests. The survey was sent to emergency clinicians (ECs) in a teaching hospital in London, UK, between May and September 2022. Semistructured interviews were conducted simultaneously, and data examined using direct content analysis. Implementation strategies were then selected based on the Expert Recommendations for Implementing Change framework.

RESULTS

Fifty-one ECs responded to the survey and six ECs volunteered for interview. Less than half reported using the bedside tests to make a diagnosis. The most common barriers were beliefs about complexity, a lack of supporting materials, memory, lack of skills and negative experiences. The interview data revealed negative beliefs about the necessity, validity, safety and practicality. There were also barriers in the ED environment (eg, lack of space). There was a strong perception that the current approach to managing acute vertigo needed to change and ECs view this as part of their professional role and responsibility. Based on clinician input, the authors selected strategies to improve diagnostic efforts, which included guidelines for training, developing vertigo champions, protocols, memory aids, audit and feedback.

CONCLUSION

This study found several barriers to managing acute vertigo such as memory constraints, and inadequate supporting materials and training, although a robust desire for change. The implementation strategy's initial phase is described, which must now be tested.

Classic form of eosinophilic pustular folliculitis in an immunocompetent girl: rapid and complete resolution after low-dose oral indomethacin treatment

Eosinophilic pustular folliculitis (EPF) is a rare noninfectious pruritic dermatosis, first described by Ise and Ofuji in 1965. We report the case of a 15-year oldimmunocompetent girl that presented with a widespread papulopustular eruption four days after her arrival in Japan. The clinical diagnosis of the classicform of EPF was confirmed by histological examination of the lesional skin that revealed an intense, mainly eosinophilic, dermal infiltrate within and aroundpilosebaceous units. Oral administration of lowdose indomethacin (25 mg/day) led to a complete resolution of the eruption within 6 weeks without causing any side effects. The patient is presently completing a 15-month follow-up and remains free ofrelapses. To the best of our knowledge, it is the first time that low-dose oral indomethacin is reported to be capable of causing a rapid and complete resolutionof the classic form of EPF.

Primary stability of two uncementedacetabular components of different geometry: hemispherical or peripherallyenhanced?

Objective

This study compared the primary stability of two commercially available acetabular components from the same manufacturer, which differ only in geometry; a hemispherical and a peripherally enhanced design (peripheral self-locking (PSL)). The objective was to determine whether altered geometry resulted in better primary stability.

Methods

Acetabular components were seated with 0.8 mm to 2 mm interference fits in reamed polyethylene bone substrate of two different densities (0.22 g/cm³ and 0.45 g/cm³). The primary stability of each component design was investigated by measuring the peak failure load during uniaxial pull-out and tangential lever-out tests.

Results

There was no statistically significant difference in seating force (p = 0.104) or primary stability (pull-out p = 0.171, lever-out p = 0.087) of the two components in the low-density substrate. Similarly, in the high-density substrate, there was no statistically significant difference in the peak pull-out force (p = 0.154) or lever-out moment (p = 0.574) between the designs. However, the PSL component required a significantly higher seating force than the hemispherical cup in the high-density bone analogue (p = 0.006).

Conclusions

Higher seating forces associated with the PSL design may result in inadequate seating and increased risk of component malpositioning or acetabular fracture in the intra-operative setting in high-density bone stock. Our results, if translated clinically, suggest that a purely hemispherical geometry may have an advantage over a peripherally enhanced geometry in high density bone stock.

Cite this article: Bone Joint Res 2013;2:264–9.

Human and canine leishmaniasis in asymptomatic and symptomatic population in Northwestern Greece

The occurrence of human and canine Mediterranean visceral leishmaniasis (MVL) in Northwestern Greece was investigated during an 8-year survey (1994-2001). A total of 1200 blood sera samples, collected from asymptomatic human population, and 1200 blood sera samples from asymptomatic dogs were screened for Leishmania infantum antibodies using the indirect immunofluorescence test (IFA). Also during the survey 111 human subjects and 350 canines were referred as clinically suspect cases for MVL. Significant differences (p = 0.001) were found between the prevalence of MVL in symptomatic and asymptomatic human populations (12.6 and 0.5%, respectively), but a more modest difference was observed between symptomatic and asymptomatic canines (45.4 and 24.4%, respectively). From the results, it appears that Greece has a high background of canine leishmaniasis, which is likely to be a risk factor for the emergence of human MVL.

Bacterial strains isolated from eggs and their resistance to currently used antibiotics: is there a health hazard for consumers?

In order to study the putative transfer of antibiotic resistance from poultry to humans, hens' eggs were examined for the presence of various pathogens. Staphylococcus, Enterobacter, Escherichia, Proteus and Pseudomonas spp. were the most frequently isolated genera. Sensitivity tests, performed with the Kirby-Bauer technique, showed the presence of resistant strains of Staphylococcus aureus (to penicillin-G, tetracycline, erythromycin, clindamycin, cefalosporins, oxacillin, gentamycin, chloramphenicol and tobramycin), Enterococcus faecalis (to ampicillin, ciprofloxacin, clindamycin, gentamycin and tetracyclin), Escherichia coli (to tetracycline, erythromycin, ampicillin and cefalosporins), Enterobacter cloacae (to ampicillin, amoxycillin plus clavunalic acid, erythromycin and tetracycline), Pseudomonas stutzeri (to erythromycin and chlorampenicol) and Citrobacter freundii (to ampicillin, amoxycillin plus clavunalic acid, cefalosporins and co-trimoxazole).

Survival of enterobacteria in liquid cultures during microwave radiation and conventional heating

Bacteria in food have been reported to survive in larger numbers after processing by microwave radiation than after conventional processing. The bactericidal effect of a domestic microwave oven (SHARP R-7280) on certain pathogenic enterobacteria species was investigated in vitro, in comparison with conventional heating (boiling). The death rates of different nosocomial strains of Escherichia coli, Salmonella sofia, Salmonella enteritidis, Proteus mirabilis and Pseudomonas aeruginosa were tested. The microwave oven and the conventional heating system used were both calibrated in order to calculate temperatures from exposure times. For each strain duplicate samples of 25 ml of pure culture with concentrations at least 10(6) cfu/ml were exposed to microwave radiation. An equal number of samples of the same volume and concentration were exposed to conventional heating. Subsequently all samples were examined qualitatively and quantitatively following standard microbiological procedures. The results indicate that microwaves have an efficient bactericidal effect on the enterobacteria in liquid cultures.

Detection of chlamydia trachomatis antigen using the direct immunofluorescence technique: a four year survey in Northwestern Greece

The prevalence of Chlamydia trachomatis antigen in patients visiting the University Hospital of Ioannina, North-western Greece during 1991-1993 is surveyed. Six hundred and twenty two (622) samples (scrapings from the cervix, uretra and conjunctiva) were examined for the detenction of C. trachomatis antigen using the direct immunofluorescence technique (DIF). From the 662 samples examined by DIF, 579 were found negative (93%) and 43 positive (7%).

[Primary observation of a congenital intracranial teratoma in a twin with a healthy brother]

Primary intracranial teratomas are rare germ cell tumors arising from embryonic tissues, which contain cellular or tissue derivates from all three germ layers. Today the early intrauterine diagnosis by ultrasound is possible. We first describe a patient with such a tumor which was diagnosed by routine ultrasound in the 33rd week of gestational age in a twin-pregnancy, of which the 2nd twin developed normally. This must be considered in the obstetrical situation. In such a case the parents should be advised accordingly.