Clinical practice guideline and pathways for the evaluation and management of patients with dizziness in family and community practice

Background@#Dizziness is a commonly encountered symptom in the primary care which can be caused, most of the time by benign condition and rarely due to serious conditions needing higher level of care.@*Objective@#To develop a clinical guideline and pathway that will serve as guide in the diagnosis and management of adult patients with dizziness in primary care and outpatient setting@*Methods@#A guideline development team was formed which is composed of family and community medicine specialists from different institutions. Searching, selection and assessment of the latest evidence on dizziness diagnosis and management was done using the search terms: “dizziness”, “diagnosis”, “management”, and “primary care”. Formulation of the recommendation was done using Grade approach and graded with modified GRADEPro and expert panel consensus. External review was also done by an expert in otorhinolaryngology.@*Recommendations@#Clinical Assessment •Recommendation1.Askforthepatient’sdescriptionofdizzinessandclassifythepatientintooneofthefourtypes: vertigo, presyncope, disequilibrium, and lightheadedness and classify as acute/episodic or chronic/sustained. (Strong Recommendation, Low Quality Evidence) •Recommendation2.Obtainamedicalhistoryfocusingonthetiming,triggers,associatedsymptoms,riskfactorsfor atherosclerotic vascular disease, and functional status or quality of life. (Strong Recommendation, High Quality Evidence) •Recommendation3.Performaphysicalexaminationfocusingonvitalsigns,HEENT(includingotoscopy),cardiovascular and neurologic examination. (Strong Recommendation, High Quality Evidence) •Recommendation4.PerformspecialphysicalexaminationslikeDix-Hallpikemaneuverforacuteepisodictriggeredvertigo to check for BPPV (most common cause of peripheral vertigo), HINTS plus test for spontaneous episodic vertigo to check for stroke and hyperventilation provocation test for patients suspected of anxiety (Strong Recommendation, High Quality Evidence) •Recommendation5.Elicitredflagsthatshouldwarrantreferrallikeseveredizzinessandassociated,alteredmentalstatus, loss of consciousness and abnormal vital signs. Other symptoms like chest pain, palpitations, dyspnea, neurologic deficit may warrant referral for evaluation and management. (Strong Recommendation, High Quality Evidence) •Recommendation6.Forpatientsconsultingviatelemedicine,obtainamedicalhistoryfocusingonthetiming,triggers, associated symptoms, risk factors for atherosclerotic vascular disease, and functional status or quality of life, and observe and conduct self-physical examination (vital signs, mental status, ocular and facial nerve) (Strong Recommendation, Low Quality Evidence) Diagnostic •Recommendation7.Laboratorytestingisnotroutinelyrecommendedamongpatientswithdizziness.However,testingmay be requested if there is a need to identify a definite etiology to guide treatment and should be guided by the classification of dizziness, possible etiology, and the medical history and physical examination. (Strong Recommendation, High Quality Evidence).Recommendation8.Forpatientswithvertigoandwithauditorysymptoms(i.e.,hearingloss,tinnitusandauralfullness, etc.), pure tone audiometry speech test may be requested if available. (Strong Recommendation, High Quality Evidence) •Recommendation9.Forpatientswithpresyncope/syncopeandachronicmedicalconditionisbeingconsidered,complete blood count may be requested for those with probable blood dyscrasia, serum blood glucose may be requested for those with diabetes, electrocardiogram and lipid profile may be requested for those with cardiovascular disease. (Strong Recommendation, High Quality Evidence) •Recommendation10.Forpatientswithdisequilibriumandwithanabnormalneurologicphysicalexaminationfinding,CT scan may be requested. (Strong Recommendation, High Quality Evidence) Pharmacologic •Recommendation11.Empirictrialofshortcourse(7days)pharmacologictreatmentforsymptomreliefshouldbeoffered. Referral should be considered if the dizziness become more severe or it did not improve in 7 days. (Strong Recommendation, High Quality Evidence) •Recommendation12.Forpatientswithmildtomoderatevertigo,offerhistamineanalogue(betahistine)orantihistamine (meclizine, diphenhydramine, dimenhydrinate or cinnarizine) for symptom relief. (Strong Recommendation, High Quality Evidence) •Recommendation13.Forpatientswithmildtomoderatevertigoassociatedwithmigraine(vestibularmigraine),aside from symptom relief, offer any of the triptans as preventive medication. (Strong Recommendation, High Quality Evidence) •Recommendation14.Forpatientswhosedizzinessisdescribedasdisequilibrium(gaitimbalance)orpresyncope(near faintness) or dizziness with anxiety attack, offer symptomatic treatment and intervention based on the underlying cause or consider referral to appropriate specialist. (Strong Recommendation, High Quality Evidence) Non-pharmacologic •Recommendation15.Allpatientsshouldbeprovidedwithhealtheducationoncauses,triggersandfollowup.(Strong Recommendation, Low Quality Evidence) •Recommendation16.Allpatientsshouldbeadvisedonappropriatedietandlifestylemodification.(StrongRecommendation, Low Quality Evidence) •Recommendation17.Dependingonthenatureofvertigo,educateandtrainthepatientoncanalrepositioningmaneuver and vestibular rehabilitation. Referral to rehabilitation medicine may be considered. (Strong Recommendation, High Quality Evidence) •Recommendation18.Thepatient’sfamilymustalsobeprovidedwithhealtheducationandidentifyacaregivertoassist and promote compliance to management. (Strong Recommendation, Low Quality Evidence) •Recommendation19.Encouragecommunity-basedvestibularrehabilitationactivitiessuchasgroupbalancetraining exercise. (Strong Recommendation, Low Quality Evidence) Patient Outcomes •Recommendation20.Thepatientshouldknowthenatureofdizziness,causesandpotentialcomplicationsanddevelop skills in postural exercises. (Strong Recommendation, Moderate Quality Evidence) •Recommendation21.Decreaseinfrequencyandseverityshouldexpectedwithin48hoursandresolutionisexpectedwithin a month. (Strong Recommendation, Moderate Quality Evidence) •Recommendation22.Improvedqualityoflifeshouldalsobeelicited.(StrongRecommendation,ModerateQualityEvidence) •Recommendation23.Referraltoappropriatespecialtyshouldbedoneifnoresolutionorprogressionofsymptomsor impaired quality of life for more than a month. (Strong Recommendation, Expert Opinion)@*Implementation@#The committee shall disseminate the guidelines through presentations and via journal publications. The QA committee shall be in charge of implementation of the guideline and pathway.

Partnership Between Families of Children with Muscular Dystrophy and Health-care Professionals: From Parents' Perspective

PURPOSE: At present, there is still controversy between parents of children with muscular dystrophy (MD) and health-care professionals on care issues. Partnerships can connect the affected children and their families to appropriate health-care services, to jointly face the care environment together and thereby improve the quality of life of children with MD. Therefore, the objective of this study was to explore partnerships between families and health-care professionals from the perspectives of parents of children with MD. METHODS: Husserl's phenomenological research was applied to explore the basic structures of parents' descriptions of MD. Through purposive sampling, we conducted in-depth interviews with parents, and analyzed the data according to the theory of Giorgi. Nineteen parents (10 mothers, 9 fathers) participated in this study. The precision of the research results was tested by applying the four standards of Lincoln and Guba. RESULTS: This study identified five constituents: feasible resources and detailed care information; the provision of an integrated medical care across systems; family and home as key elements in critical care; respect and care for family care demands; and finally, feedback and support from families. CONCLUSION: This study demonstrated that partnerships were established by health-care professionals, enhancing the care capacity of the families, developing the preventive medicine of MD, and enhancing children's potential for self-care within the families. Hospital policies should include the promotion of family partnership care. The findings can help health-care professionals recognize the life experiences of children with MD when providing medical care.

Global health: a lasting partnership in paediatric surgery

Background: To emphasise the value of on-going commitment in Global Health Partnerships. Materials and Methods: A hospital link; by invitation; was set up between United Kingdom and Tanzania since 2002. The project involved annual visits with activities ranging from exchange of skill to training health professionals. Furthermore; the programme attracted teaching and research activities. For continuity; there was electronic communication between visits. Results: Six paediatric surgeons are now fully trained with three further in training in Africa. Paediatric surgery services are now separate from adult services. Seven trainee exchanges have taken place with four awarded fellowships/scholarships. Twenty-three clinical projects have been presented internationally resulting in eight international publications. The programme has attracted other health professionals; especially nursing and engineering. The Tropical Health and Education Trust prize was recently achieved for nursing and radiography. National Health Service has benefited from volunteering staff bringing new cost-effective ideas. A fully funded medical student elective programme has been achieved since 2008. Conclusion: Global Health Partnerships are an excellent initiative in establishing specialist services in countries with limited resources. In the future; this will translate into improved patient care as long as it is sustained and valued by long term commitment

[Professional partnership: nurses' experience of theory-practice gap in nursing education]

Examining the gap between theoretical and practical training can be effective in professional development and can be changed. The aim of this study was to determine the experiences of nursing teachers about the issue of gap between theory and practice in nursing education. This qualitative study was carried out on 32 nursing teachers and managers at Nursing and Midwifery Faculties of Ahvaz Jundishapur University of Medical Sciences, Tehran University of Medical Sciences and Esfahan University of Medical Sciences. Data collection conducted using semi-structured interview and after signing the informed consent by the participants. The interviews were recorded and transcribed. Then, collected data were analyzed through conventional content analysis. In order to assess the validity of data collection, different criteria such as acceptability and verifiability were used. Main themes of the research include education engineering, meritocratic and professional partnership. Experience and understanding of the participants showed that their professional practice and educational activities are in compliance with the core planning. Therefore, content of education and clinical credibility and competency should be standardized through acquired efficient partnership. This will reduce the gap between education and training. The results of this study provides knowledge and insight in educators and managers, so that that they would be able to confront and resolve the gap between theory and clinical training. Results of this study revealed that experiences of participants can identify factors affecting the challenge and provide improved status appropriate for enhanced competence and capabilities of nursing student

Potentialities for community and rural development through voluntary and governmental health professions partnership: a case study from south Kordofan [1995 - 2000]

Developing countries are confronted by multiple challenges. Civil conflicts and war, rapid population movements and displacement, poor rural infrastructure settings and destruction of existing ones, economical recession and malutilization of resources and bureaucracy, are some but not all. Partnership is needed and new players for a new era are to be introduced. Non-governmental agencies can play that role through partnership with governments and history of the post-war Europe is an example. In this study a similar experience from Sudan is under appraisal whereby a leading non-governmental organization, Benevolence International Foundation [BIF] has been, and through partnership with the State Health Authorities, implementing health and other social activities in some of the most needy rural suburbs of Kadogli Province in South Kordofan State. The population served by BIF in these locations mount to a bit more than 25% of the total population of the province. Through implementing Primary Health Care Projects in eleven locations in that area which suffer from the severe and devastating effects of the civil war that has been going on for long and where official role of the government is almost nil, BIF intends and endeavors to mobilize and develop that rural communities. The aim of this essay is to determine if BIF has succeeded and to what extend in inducing change in that communities through highlighting on the major achievements and also to disclose some of the weaknesses and obstacles encountered. The work was an observational descriptive survey covering all the locations of south and west rural suburbs of Kadogli Province through a non-probability sampling technique and starting from late 1995 and up to the end of 1999. The results included populations covered in each peace village, distance from Kadogli city, PHC components performed and those still left undone per clinic, number and classification of practicing health personnel and of those who had a chance for training, and components of community development motivated as indices for success of failure in inducing a positive change in that populations. The study concluded with the affirmation to the importance of voluntary governmental partnership in developing underprivileged communities and in inducing rural development and assured on the role that NGOs can play by making use of the lessons learned from BIF experience in South Kordofan

Partnership Replaces Paternalism in Medical Practice

"The belief and practice that doctors know best what is good and suited for their patients is deeply rooted among practicing doctors in Uganda. It is benign; and may be well intentioned; but it has had the effect of creating and maintaining an unhealthy dependency which is now out of step with currents elsewhere or even with out currents in Uganda. Assumptions that doctor; nurse or midwife knows best; making all decisions on behalf of patients without involving them; and feeling threatened or offended when patients ask questions or make suggestions - these signs of patermilism should have no place in modern health care. In this article I consider the scope for creating meaningful partnership between doctors and patients. ""Paternalism"" has no further part to play in health care delivery now; and most countries have embraced or are embracing ""partnership""; which is known to greatly increase patients satisfaction and compliance; and also increases the rate of recovery from their illnesses."

Factores asociados a la práctica de la lactancia: II. Estudio de mujeres sin control prenatal / Factors associated with breast feeding: II. study of women with no prenatal control

Se revisan los casos sin control prenatal de un estudio prospectivo sobre práticas de la lactancia. La finalidad es identificar con la mayor precisión factores que intervienen o determinan las prácticas de alimentación infantil dentro de la que interesa destacar las diferencias que se encuentran entre instituciones con diferentes esquemas de atención. Con el fin último de evaluar si las características distintivas que se encuentran son atribuibles a las mujeres y su entorno o a las instituciones y sus políticas o, lo que es más probable, algún tipo de interacción entre ambos donde, se espera una mayor determinación social y una menor institucional. Se presentas la información de 582 mujeres que sólo acudieron a la atención del parto en tres instituciones de salud: promoción de la lactancia y no dotación de sucedáneos de leche (Hospital A: 252 mujeres); no promoción de la lactancia y dotación de sucedáneos de leche (Hospital B: 80 mujeres); y no promoción de la lactancia y no dotación de sucedáneos de leche (Hospital C: 250 mujeres). En el análisis, se encontró que el hospital A presentó: la menor proporción de madres que viven actualmente en un azona rural; la mayor proporción de mujeres con niveles más altos de escolaridad (secundaria o más); sus compañeros mostraron la menor frecuencia de analfabetos o con niveles más bajos de educación (analfabetos, primaria completa); este mismo comportamiento lo presentaron sus madres; la mayor proporción de mujeres con más de una muerte intrauterina y también mostró el mayor número de mujeres que no lactaron a su bebé anterior; por otro lado en el hospital B se encontró la mayor proporción de mujeres que sí viven con el papá del bebé y las que más reciben ayuda econímica por parte de él y el mayor número de mujeres que no recibieron nuevas ideas con la información recibida fuera de la institución; para finalizar, el hospital C msotró: la mayor proporción tanto de mujeres nacidas en un área rural como de madres analfabetas, fueron las mujeres que más recibieron información sobre la lactancia fuera de la institución. Es muy probable que las diferencias socioculturales y demográficas encontradas sean más delimitantes de la práctica que la influencia de la institución hospitalaria