Positive Resource Center

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Lack of both awareness and application of evidence-based principles for obesity care for people with obesity (PwO) limit employers' role in supporting effective obesity management among employees with obesity (EwO). The aim of the ACTION (Awareness, Care, and Treatment In Obesity maNagement) study was to explore the current state of employer wellness programs related to obesity management, evaluate the impact of obesity in the workplace, assess attitudes regarding the role of employers in managing obesity, and identify challenges in implementing workplace wellness programs as perceived by employer representatives (ERs) and EwO. An online survey was conducted among ERs and adult PwO (BMI ≥30 by self-reported height and weight) using a cross-sectional, US-based stratified sample design. There were 153 ER respondents and 3008 adult PwO respondents; 1478 PwO were employed full-time, part-time, or were self-employed. ERs recognize the seriousness of obesity and its negative impact on work productivity; however, wellness programs tend to fall short of addressing specific needs of EwO, evidenced by low participation and success rates reported by EwO. This study highlights the need for programs that address the complexities of obesity and the specific needs of EwO, which currently are inadequately addressed according to EwO.

Debates about the productivity impact of work accommodations typically focus on employment and labor force participation outcomes. This study considers whether accommodations mediate on-the-job productivity losses among employees who report health problems. The study uses ordered logistic regression to predict employees' self-reported productivity losses as a function of health problems and experiences with needed work accommodations. On average, the odds that an employee who did not get a needed accommodation reported higher levels of lost productivity are 5.11 times the odds for an employee who got a needed accommodation. Although health problems make it difficult for many employees to perform well on the job, accommodations could reduce productivity losses in some cases. Nonetheless, more research on the impact of specific kinds of accommodations for different chronic conditions is warranted.

Modifiable health risks such as smoking, exercise, and body weight have been linked to illness absence from work. This suggests that employers could improve their productivity if their workers adopted healthier lifestyles, but methodological concerns regarding selection bias and omitted variables remain. We use a first-difference model of changes in health behaviors and illness- and family-related absence from work among a nationally representative, longitudinal panel of employed individuals. Workers who lost weight or increased their frequency of light exercise also saw their illness absences decrease over a 2-year period. Some, but not all, of the relationship is mediated by the change in health status. No such decrease was observed for family-related absences. The findings are consistent with the proposition that both employers and employees could benefit from efforts to support better health habits.

A cohort study analyzing the cervical range of motion (ROM) of subjects with 4- or 5-level posterior laminectomy and fusion or anterior and posterior decompression and fusion operation. The purpose of this study was to evaluate the effect of extending a C3-C7 fusion to C3-T1 on subject's ROM and level of disability. Cadaveric studies show a reduction in the ROM of C3-C7 cervical fusion spines. In vivo, surgeons treat symptomatic cervical subaxial spine with either a C3-C7 fusion or C3-T1 fusion. While in some cases extending the fusion level to T1 is merited due to pathology, most cases are due to surgeon's preference to avoid future degeneration and reoperation of the C7-T1 junction. This study involved 44 4-level fusion and 20 5-level fusion subjects along with 18 nonoperative controls. Operative subjects were divided according to early or late postoperative clinical visit. Subjects were asked to complete the neck disability index survey and their maximum ROM during flexion/extension, axial rotation, and lateral bending was measured using a virtual reality assisted electromagnetic tracking system. In addition, the helical axis of motion was calculated for flexion and extension motions. An analysis of variance statistical test was used to determine significant differences between study groups. Five- level subjects had significantly less ROM than 4-level subjects and both groups were significantly less than control group during all motions. There was no effect of postoperative time on subject's ROM. In addition, there was no difference in the center of helical axis of rotation across the 3 groups. Finally, both operative groups exhibited similar levels of mild disability as measured by the neck disability index. Extending the subaxial fusion from C3-C7 to include C7-T1 resulted in a significant loss of ROM, while postoperative time healing, center of rotation, and level of disability were similar across groups. This finding merits further investigation of the intersegmental motions of the cervical spine.

The Centers for Disease Control (CDC) recommends sexually transmitted disease (STD) screening among HIV-infected persons in order to reduce HIV transmission. We evaluated the results of routine screening for syphilis and for urogenital, pharyngeal, and rectal gonorrhea (GC) and chlamydia (CT) among asymptomatic HIV-infected patients at an HIV primary care clinic in San Francisco, California. We found 15 new syphilis infections of 814 tested (1.8%) and 60 new cases of CT or GC infection of 586 tested (10.2%), with 88% of GC and CT infections occurring at nonurethral sites. Our study reveals a high rate of asymptomatic STDs among HIV-infected patients in primary care and supports the CDC recommendations to screen HIV-infected patients for STDs at all relevant anatomic sites.

To test the hypothesis that higher levels of participation and functioning in cross-functional psychiatric treatment teams will be related to improved patient outcomes. Primary data were collected during the period 1992-1999. The study was conducted in 40 teams within units treating seriously mentally ill patients in 16 Veterans Affairs hospitals across the U.S. A longitudinal, multilevel analysis assessed the relationship between individual- and team-level variables and patients' ability to perform activities of daily living (ADL) over time. Team data were collected in 1992, 1994, and 1995. The number of times patient data were collected was dependent on the length of time the patient was treated and varied from 1 to 14 between 1992 and 1999. Key variables included: patients' ADL scores (the dependent variable); measures of team participation and team functioning; the number of days from baseline on which a patient's ADLs were assessed; and several control variables. Team data were obtained via self-administered questionnaires distributed to staff on the study teams. Additional team data were obtained via questionnaires completed by unit directors contemporaneously with the staff survey. Patient data were collected by trained clinicians at regular intervals using a standard assessment instrument. Results indicated that patients treated in teams with higher levels of staff participation experienced greater improvement in ADL over time. No differences in ADL change were noted for patients treated in teams with higher levels of team functioning. Findings support our premise that team process has important implications for patient outcomes. The results suggest that the level of participation by the team as a whole may be a more important process attribute, in terms of patient improvements in ADLs, than the team's smooth functioning. These findings indicate the potential appropriateness of managerial interventions to encourage member investment in team processes.

Unusual manifestations of osteoarticular tuberculosis, especially tubercular osteomyelitis, are described. Diagnostic problems may arise and lead to delay in treatment if these conditions are not considered in the differential diagnosis. The importance of bacteriologic and histopathologic confirmation of the disease is stressed.

To evaluate the effect of previous cerebrovascular accident on outcome after hip fracture. Prospective, consecutive. From July 1987 to March 1997, 862 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed. All patients had operative fracture treatment. Postoperative complications, in-hospital mortality, hospital length of stay, hospital discharge status, one-year mortality and place of residence, and return to preinjury ambulatory level, basic and instrumental activities of daily living status. Sixty-three patients (7.3 percent) had a history of cerebrovascular accident; the fracture was on the hemiplegic side in forty-six (86.8 percent) of the fifty-three patients with hemiplegia. Patients who had a history of cerebrovascular accident were more likely to be male and have an American Society of Anesthesiologists (ASA) rating of III or IV. They were also more likely to have three or more comorbidities, be a home ambulator, and be dependent on basic and instrumental activities of daily living before hip fracture. Hospital length of stay was significantly higher for patients who had a history of cerebrovascular accident. There were no differences in the incidence of hospital mortality or one-year mortality between patients who did and did not have a history of cerebrovascular accident before hip fracture. In addition, at one-year follow-up, when controlling for prefracture level of function, there were no differences in the rate of functional recovery between the two groups of patients. The functional recovery of elderly hip fracture patients who had a prior cerebrovascular accident was similar to that of patients who had no history of a prior cerebrovascular accident.