Comparative Study of Management of BPPV (Benign Paroxysmal Positional Vertigo) with only Drugs Versus Drugs Plus Epley Manoeuvre

Abstract

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for 20% of all vertigo cases. Idiopathic BPPV is most common between the ages of 50 and 70, although the condition is found in all age groups. The importance of early diagnosis and treatment can lead to a much improved quality of life for patients afflicted by this ailment. It is presently common for physicians to treat these patients mainly with benzodiazepines, antihistamines, and anticholinergic medications, especially if the history and physical is consistent with BPPV. This method of treatment has had questionable success. Several reviews of the management of vertigo have shown that no medication in current use has well established curative or prophylactic value or is suitable for long-term treatment. Epleys manoeuvre is also used in the treatment of BPPV. This manoeuvre relocates free floating particles from the affected semi-circular canals back into utricle, thus relieving the symptoms of vertigo. The purpose of this study is to compare the efficacy of Epleys manoeuvre with conventional drug therapy versus conventional therapy alone in patients who present with vertigo. The purpose of this study to evaluate and examine two methods of treatment.

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Antibody-Mediated Encephalitis

Antibody-mediated encephalitides constitute a group of inflammatory brain diseases that are characterized by prominent neuropsychiatric symptoms and are associated with antibodies against neuronal cell-surface proteins, ion channels, or receptors (Table 1). Common clinical features include a change…

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HER2 deregulation in lung cancer: right time to adopt an orphan?

HER2-deregulated non-small cell lung cancer is an orphan of any specific therapy probably because of lack of both accurate patient selection and effective drugs. Recent evidence suggested that osimertinib could be effective in HER2 amplified or mutated lung cancer as a single agent or in combination.

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The RNA-binding protein MEX3B mediates resistance to cancer immunotherapy by downregulating HLA-A expression

Purpose: Cancer immunotherapy has shown promising clinical outcomes in many patients. However, some patients still fail to respond, and new strategies are needed to overcome resistance. The purpose of this study was to identify novel genes and understand the mechanisms that confer resistance to cancer immunotherapy. Experimental Design: To identify genes mediating resistance to T cell killing, we performed an open reading frame (ORF) screen of a kinome library to study whether overexpression of a gene in patient-derived melanoma cells could inhibit their susceptibility to killing by autologous Tumor-Infiltrating Lymphocytes (TILs). Results: The RNA-binding protein MEX3B was identified as a top candidate that decreased the susceptibility of melanoma cells to killing by TILs. Further analyses of anti-PD-1-treated melanoma patient tumor samples suggested that higher MEX3B expression is associated with resistance to PD-1 blockade. In addition, significantly decreased levels of IFN were secreted from TILs incubated with MEX3B-overexpressing tumor cells. Interestingly, this phenotype was rescued upon overexpression of exogenous HLA-A2. Consistent with this, we observed decreased HLA-A expression in MEX3B-overexpressing tumor cells. Finally, luciferase reporter assays and RNA-binding protein immunoprecipitation assays suggest that this is due to MEX3B binding to the 3' UTR of HLA-A to destabilize the mRNA. Conclusions: MEX3B mediates resistance to cancer immunotherapy by binding to the 3' UTR of HLA-A to destabilize the HLA-A mRNA and thus downregulate HLA-A expression on the surface of tumor cells, thereby making the tumor cells unable to be recognized and killed by T cells.

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Copyright

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Contributors

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Contents

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Forthcoming Issues

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Improving Perioperative Care: What Are the Tools That Lead to Sustainable Change?

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Lee A. Fleisher




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Quality Improvement and Implementation Science

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Lee A. Fleisher




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Quality Improvement and Implementation Science: Different Fields with Aligned Goals

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Lee A. Fleisher




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Implementation Science in Perioperative Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Benjamin T. Cobb, Crystal Wiley Cené, Rinad S. Beidas

Teaser

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.


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Human Factors Applied to Perioperative Process Improvement

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Joseph R. Keebler, Elizabeth H. Lazzara, Elizabeth Blickensderfer, Thomas D. Looke

Teaser

This article discusses some of the major theories of the science of human factors/ergonomics (HF/E) in relation to perioperative medicine, with a focus on safety and errors within these systems. The discussion begins with human limitations based in cognition, decision making, stress, and fatigue. Given these limitations, the importance of measuring human performance is discussed. Finally, using the HF/E perspective on safety, high-level recommendations are provided for increasing safety within the perioperative environment.


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Quality Improvement in Anesthesiology — Leveraging Data and Analytics to Optimize Outcomes

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Elizabeth A. Valentine, Scott A. Falk

Teaser

Quality improvement is at the heart of practice of anesthesiology. Objective data are critical for any quality improvement initiative; when possible, a combination of process, outcome, and balancing metrics should be evaluated to gauge the value of an intervention. Quality improvement is an ongoing process; iterative reevaluation of data is required to maintain interventions, ensure continued effectiveness, and continually improve. Dashboards can facilitate rapid analysis of data and drive decision making. Large data sets can be useful to establish benchmarks and compare performance against other providers, practices, or institutions. Audit and feedback strategies are effective in facilitating positive change.


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Emergency Manuals

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Sara N. Goldhaber-Fiebert, Carl Macrae

Teaser

How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care.


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Use of Simulation in Performance Improvement

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Amanda Burden, Erin White Pukenas

Teaser

Human error and system failures continue to play a substantial role in preventable errors that lead to adverse patient outcomes or death. Many of these deaths are not the result of inadequate medical knowledge and skill, but occur because of problems involving communication and team management. Anesthesiologists pioneered the use of simulation for medical education in an effort to improve physician performance and patient safety. This article explores the use of simulation for performance improvement. Educational theories that underlie effective simulation programs are described as driving forces behind the advancement of simulation in performance improvement.


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Handovers in Perioperative Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Atilio Barbeito, Aalok V. Agarwala, Amanda Lorinc

Teaser

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.


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Rethinking Clinical Workflow

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Joseph J. Schlesinger, Kendall Burdick, Sarah Baum, Melissa Bellomy, Dorothee Mueller, Alistair MacDonald, Alex Chern, Kristin Chrouser, Christie Burger

Teaser

The concept of clinical workflow borrows from management and leadership principles outside of medicine. The only way to rethink clinical workflow is to understand the neuroscience principles that underlie attention and vigilance. With any implementation to improve practice, there are human factors that can promote or impede progress. Modulating the environment and working as a team to take care of patients is paramount. Clinicians must continually rethink clinical workflow, evaluate progress, and understand that other industries have something to offer. Then, novel approaches can be implemented to take the best care of patients.


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Developing Capacity to Do Improvement Science Work

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Irene McGhee, Yehoshua Gleicher

Teaser

Developing capacity to do improvement science starts with prioritizing quality improvement training in all health professions curricula so that a common knowledge base and understanding are created. Educational programs should include opportunities for colearning with patients, health professionals, and leaders. In this way, knowledge translation (also called implementation) is more effective and better coordinated when applied across organizations. Key factors that enable and drive behavior change are reviewed, as is the importance of influence and leadership. A comprehensive approach that accounts for these factors hardwires quality improvement into the health care systems and creates a culture that enables its ongoing development.


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Diffusing Innovation and Best Practice in Health Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Philip E. Greilich, Mary Eleanor Phelps, William Daniel

Teaser

Diffusing innovation and best practices in healthcare are among the most challenging aspects of advancing patient safety and quality improvement. Recommendations from the Baldrige Foundation, Institute for Healthcare Improvement, and The Joint Commission provide guidance on the principles for successful diffusion. Perioperative leaders are encouraged to applying these principles to high priority areas such as handovers, enhanced recovery and patient blood management. Completing a successful pilot project can be exciting, however, effective diffusion is essential to achieving meaningful and lasting impact on the service line and health system.


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