Clinical Evaluation of Posterior Canal Benign Paroxysmal Positional Vertigo

Background: Benign paroxysmal positional vertigo (BPPV) is a mechanical peripheral vestibular disorder which may involve any of the three semicircular canals but principally the posterior. In as much as the literature has described theories to explain the mechanism of BPPV and also contains scholarly works that elucidate BPPV; its management remains an enigma to most clinicians. To this end; this work was aimed at outlining an evidence-based best practice for most common form of BPPV. Materials and Methods: A systematic review of the literature was conducted between 1948 and June 2011 in PubMed; Embase; Ovid; and Cochrane database through the online Library of the University of Cape Town. Seventy-nine worthy articles that addressed the study were selected on consensus of the two authors. Conclusion: There is consensus for the use of canalith repositioning procedures as the best form of treatment for posterior canal canalolithiasis. However; successful treatment is dependent on accurate identification of the implicated canal and the form of lithiasis. Furthermore; clinicians should note that there is no place for pharmacological treatment of BPPV; unless it is to facilitate repositioning

The Sensitivity and Specificity of Lassa Virus IgM by ELISA as Screening Tool at Early Phase of Lassa Fever Infection

"Background: Early diagnosis; prompt treatment; and disease containment are vital measures in the management of Lassa fever (LF); a lethal and contagious arenaviral hemorrhagic disease prevalent in West Africa. Lassa Virus (LAV)-specific Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test; the gold standard for diagnosis; is unavailable in most centers. Serologic detection of LAV IgM is a more accessible tool and this work was to investigate its adequacy as an early marker for LF. Patients and Methods: A prospective case-control study conducted July 2007-March 2011 in a tertiary referral health center in Nigeria. Blood samples for test and control were evaluated for Lassa specific antigens and IgM using RT-PCR (primers S36+ and LVS 339) and indirect ELISA (Lassa Nucleo-protein (NP)-Antigen) respectively. RT-PCR outcome was used as standard to test for the sensitivity and specificity of IgM. Results: Of the 37 confirmed cases of LF infection by RT-PCR; 21 (57) were IgM positive. Amongst the 35 confirmed negative cases (control group); eight were IgM positive. The diagnostic sensitivity and specificity of the IgM assay were 57 and 77 respectively. The negative and positive predictive values of the IgM serological assay were 63 and 72 ; respectively; while the efficiency of the test was 67. Conclusion: The specificity and sensitivity of IgM as a screening tool for early detection of LF appear weak and; hence; the need for a reliable LF ""rapid screening kit"" since RT-PCR is unavailable in most centers. In the interim; ""high clinical index of suspicion;"" irrespective of IgM status; requires urgent referral to confirmatory centers."

Challenges to creating primary care teams in a public health centre: a co-operative inquiry

"Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care; family-orientated care; and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs.Methods: A co-operative inquiry group; consisting of two facility managers; an administrator; and medical and nursing staff; met over a period of nine months and completed three cycles of planning; action; observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care can be created within a typical CHC.Results: The CHC had established three practice teams; but met with limited success in maintaining the teams over time. The group found that; in order for teams to work; the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors; but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of ""chronics"". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an ""assistant"" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation; while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks; thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available; while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs; who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs; however; the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day; to be cognisant of the limitations of the building design; to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered; and not just that for the doctors and nurses.Conclusions: Key lessons learnt included the need to engage with a transformational leadership style; to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team; due to their hospital duties; was a critical factor in the breakdown of the teams.. The CHC plans to further develop practice teams; to learn from the lessons so far and to continue with the co-operative inquiry."