EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo.

OBJECTIVE: To synthesise evidence-based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations. METHOD: Current best practice models of care were synthesised into a single clinical, district-based peer-reviewed algorithm by a specialist focus group. An observational pre- and post-implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups. RESULTS: Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike-Dix performed by 27% (95% confidence interval [CI] 14-40%; defects pre-intervention 40%: post-intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2-30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18-48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15-45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post-project -4.23% (95% CI -7.20, -1.27%) (P = 0.041). CONCLUSION: Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence-based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.

Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice.

OBJECTIVE: To analyse adherence to evidence based practice in the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) in a regional ED. METHODS: Retrospective observational population study. Wyong Hospital's ED, Central Coast Local Health District, New South Wales, Australia. Medical records of patients with an ED diagnosis of BPPV (n = 101) between 2017 and 2018 were included for auditing. Adherence to clinical practice guidelines for BPPV4 statements 1a, 3a, 4a and 6 were reviewed as primary outcomes using a de-identified binary data excel tool. These outcomes were compared to available data from metropolitan tertiary EDs both in Australia and the USA. RESULTS: General compliance to best practice standards was low. Of patients diagnosed with BPPV in the ED only 45% (95% CI 35-54%) were diagnosed with the recommended Hallpike-Dix positional test. Of those patients who did receive diagnosis via the Hallpike-Dix test only 41% (95% CI 28-56%) went on to receive gold standard recommended treatment of a canalith repositioning manoeuvre/technique. In regards to the recommendations against practice, 36% (95% CI 28-46%) had neuroimaging performed in the ED and 58% (95% CI 48-68%) received vestibular suppressant medication as their only treatment prior to discharge. CONCLUSION: Adherence to best practice diagnosis and management of BPPV was low in Wyong Hospital's ED. Although low, Wyong Hospital's ED appeared to perform better in compliance to the clinical guidelines to its metropolitan Australian peer. There is opportunity to improve the efficiency and effectiveness in the management of acute peripheral dizziness in EDs.

Progressive multifocal leukoencephalopathy associated with a lymphoproliferative disorder treated with pembrolizumab.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease affecting the central nervous system as a result of reactivation of the John Cunningham (JC) polyomavirus and occurs almost exclusively in immunosuppressed individuals. The disease course of PML is variable but usually progressive and often fatal. Treatment is predominantly focused on immune restoration, although this is difficult to do outside of human immunodeficiency virus-associated PML. A recent case series demonstrated a potential role for programmed cell death protein 1 (PD-1) inhibitors, such as pembrolizumab, to contain and/or clear JC virus. Herein, we discuss the first reported Australian case of a 61-year-old female with PML secondary to chemoimmunotherapy demonstrating complete clearance of JC virus as well as clinical and radiological stabilisation following pembrolizumab treatment.

Implementation of multimodal computed tomography in a telestroke network: Five-year experience.

AIMS: Penumbral selection is best-evidence practice for thrombectomy in the 6-24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre-including noncontrast CT, CT perfusion, and CT angiography-may enhance reperfusion therapy decision-making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision-making for thrombolysis. METHODS: Consecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision-making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria. RESULTS: A total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7-18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non-thrombolysed group. CONCLUSION: Implementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.

Characterising the experience of interaction: an evaluation of automotive rotary dials.

Optimising sensory product qualities is a priority for automotive manufacturers when developing human-machine interfaces, as user experience frameworks consider sensory aesthetics to be a main influencing factor of the overall judgement of product appeal. This empirical study examines whether users' overall judgements of product appeal can be predicted from measures of non-visual aesthetic qualities. Ninety-one UK owners of Supermini segment cars assessed five examples of rotary temperature dials. Factor analysis gave four clear factors common across all samples, of which 'unrefined loudness' and 'positivity/precision' predicted up to 26% variance in the hedonic score; both factors were similarly important in the regression models. Significant differences in appeal were observed between the samples; however, there were no effects due to age or gender. Practitioner Summary: The research shows that the overall appeal of automotive rotary dials is partially predicted by their non-visual aesthetics. These findings are applicable to the design of any products where improving the user experience is a goal, as it demonstrates that user experience models are applicable to product domains other than computing and information technology.

Understanding customers' holistic perception of switches in automotive human-machine interfaces.

For successful new product development, it is necessary to understand the customers' holistic experience of the product beyond traditional task completion, and acceptance measures. This paper describes research in which ninety-eight UK owners of luxury saloons assessed the feel of push-switches in five luxury saloon cars both in context (in-car) and out of context (on a bench). A combination of hedonic data (i.e. a measure of 'liking'), qualitative data and semantic differential data was collected. It was found that customers are clearly able to differentiate between switches based on the degree of liking for the samples' perceived haptic qualities, and that the assessment environment had a statistically significant effect, but that it was not universal. A factor analysis has shown that perceived characteristics of switch haptics can be explained by three independent factors defined as 'Image', 'Build Quality', and 'Clickiness'. Preliminary steps have also been taken towards identifying whether existing theoretical frameworks for user experience may be applicable to automotive human-machine interfaces.