Improving Nasopharyngeal Swab Technique via Simulation for Frontline Workers.

OBJECTIVES/HYPOTHESIS: Nasopharyngeal swabs currently remain the gold standard for COVID-19 sample collection. A surge in testing volume has resulted in a large number of health care workers who are unfamiliar with nasal anatomy performing this test, which can lead to improper collection practices culminating in false-negative results and complications. Therefore, we aimed to assess the accuracy and educational potential of a realistic 3D-printed nasal swab simulator to expedite health care workers' skill acquisition. STUDY DESIGN: Prospective pre-post interventional study. METHODS: A nasal swab task trainer (NSTT) was developed to scale from computed tomography data with a deviated septum. Frontline workers at COVID-19 testing sites in Ontario, Canada, were recruited to use the NSTT for nasopharyngeal swab training. Integrated video recording capability allowed participants to self-evaluate procedure accuracy. A five-point Likert scale was collected regarding the NSTT's educational value and procedural fidelity. RESULTS: Sixty-two frontline workers included in the study were primarily registered nurses (52%) or paramedics (16%). Following simulator use, self-assessed accuracy improved in 77% of all participants and 100% of participants who expressed low confidence before training. Ninety-four percent reported that the NSTT provided a complete educational experience, and 82% regarded the system as a more effective training approach than what is currently available. Eighty-one indicated that the simulator should be used at all COVID-19 testing sites, with 77% stating province-wide implementation was warranted. CONCLUSIONS: The nasal swab task trainer is an effective educational tool that appears well-suited for improved skill acquisition in COVID-19 testing and may be useful for training other nasal swab applications. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:38-42, 2023.

Benign Paroxysmal Positional Vertigo.

Purpose of Chapter: This chapter discusses the recent progress made in understanding the pathophysiology, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV). Recent Findings: Recent evidence supports the canalolithiasis model as the pathophysiological mechanism and predominant subtype of BPPV. Scanning electron micrographs of extracted posterior semicircular canal contents show free-floating otoconia of utricular origin. Calcium homeostasis has also been shown to contribute to the pathogenesis of the disorder by creating an environment in which otoconia are more prone to dislodging from their native gelatinous substrate. Recent findings have served to identify variant-specific provocative tests with the greatest diagnostic utility while simultaneously maximizing their diagnostic yield. Current data have also helped elucidate the efficacy of repositioning maneuvers and surgical interventions. Summary: BPPV is a disease of altered endolymph and cupular mechanics secondary to dislodged otoconia. It is amenable to particle repositioning maneuvers in most instances or surgical occlusion for intractable cases.

Intratympanic Dexamethasone in the Treatment of Ménière's Disease: A Comparison of Two Techniques.

OBJECTIVE: To assess the efficacy and safety of two different intratympanic dexamethasone (IT Dex) injection protocols for intractable unilateral Ménière's disease. STUDY DESIGN: Prospective case series. SETTING: Tertiary neurotology clinic. PATIENTS: One hundred six consecutive adult patients with definite unilateral Ménière's disease who had failed medical management were studied for an average of 1,061 days. None had previous oral steroid, IT steroid, or ablative treatment. INTERVENTIONS: Two different IT Dex regimes, either a single injection or a series of four injections, that were subsequently repeated as indicated. MAIN OUTCOME MEASURE: Requirement for subsequent ablative therapy in the form of intratympanic gentamicin, vestibular nerve section, or labyrinthectomy. Hearing outcomes were measured using pure-tone average of 0.5, 1, 2, and 3 kHz on standard audiometry. RESULTS: The number of intratympanic dexamethasone injections per patient ranged from 1 to 29 (median = 4). Using the Kaplan-Meier method, predicted survival (patients not requiring ablative therapy) at 2 and 4 years after initial treatment was 83.9 and 79.3%, respectively. The injection series protocol ultimately yielded 5% better survival than the single injection protocol, but this was not statistically significant. Injections did not protect against hearing loss, and the most recent pure-tone averages declined compared with pretreatment values by an average of 8.27 dB (p < 0.05). The treatments did not result in any acute hearing losses, permanent tympanic membrane perforations, or other significant adverse events. CONCLUSION: Intratympanic dexamethasone injections were successful in controlling vertigo insofar as they were able to obviate ablative therapy in the majority of Ménière's disease patients in this study. The injection series protocol may have been more beneficial compared with the single injection, although the difference between the two protocols was nonsignificant. Hearing mildly declined over the treatment course, which likely represents natural disease progression. The lack of adverse events suggests that IT Dex may be a nonablative option for patients with bilateral disease or only hearing/vestibular ears.

Improvement evident but still necessary in clinical practice guideline quality: a systematic review.

OBJECTIVE: To review the quality of clinical practice guidelines (CPGs) from a wide range of health care topics and report any changes seen since 1992. STUDY DESIGN AND SETTING: A literature search in MEDLINE, EMBASE, Web of Science Core Collection, and BIOSIS was conducted in London, Ontario, Canada. Publications were screened to identify those assessing the quality of CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Data were gathered regarding year of publication, institution type, health topic, country of origin, domain scores, and final recommendation. RESULTS: Twenty-five studies met the inclusion criteria. AGREE II scores from 415 individual CPGs published between 1992 and 2014 were obtained. Domain scores increased significantly over time, and the proportion of guidelines being recommended based on AGREE II assessment was significantly greater after 2010. Domain scores in Applicability and Editorial independence had no significant effect on a CPG's final recommendation, whereas other domains had a significant effect. Finally, international development groups produced CPGs with significantly higher scores. CONCLUSION: This review found a steady improvement in CPG quality over time. This is particularly evident in guidelines published after 2010. However, certain domains that are integral to the methodological quality of CPGs remain unsatisfactorily low.