What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

BackgroundVertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient.Materials and methodsBoard-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses.ResultsA vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30–40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01–4.81], p = 0.048).ConclusionThe assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as “HINTS” and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals

Preventive Effects of Omega-3 and Omega-6 Fatty Acids on Peroxide Mediated Oxidative Stress Responses in Primary Human Trabecular Meshwork Cells

Pathologic processes in glaucoma include increased apoptosis, accumulation of extracellular material in the trabecular meshwork and optic nerve, condensations of the cytoskeleton and precocious cellular senescence. Oxidative stress was shown to generate these alterations in primary ocular cells. Fatty acids omega-3 and -6 are alleged to constitute a prophylaxis against these deleterious effects. Here, we tested actual preventive effects omega-3 and -6 against peroxide induced stress responses in primary human trabecular meshwork cells. Changes of mitochondrial activity, proliferation, heat shock proteins, extracellular matrix components, and inflammatory markers were evaluated. Alterations of the cytoskeleton were evaluated by phalloidin labeling. Here we report a repressive effect of omega-6 on metabolic activity and proliferation, which was not detected for omega-3. Both agents were able to prevent the anti-proliferative effect of H2O2, but only omega-3 prevented metabolic repression. Expression of heat shock protein 27 was unaltered by both fatty acids, whereas heat shock protein 90 was significantly induced by both. Omega-6 increased fibronectin and connective tissue growth factor synthesis, as well as the amount of secreted fibronectin. Omega-3, instead, induced plasminogen activator inhibitor 1 synthesis. H2O2 further increased fibronectin production in omega-6 supplemented cells, which was not the case in omega-3 treated cells. H2O2 stimulation of plasminogen activator inhibitor 1 and connective tissue growth factor was repressed by both fatty acids. Both fatty acids appeared to abolish H2O2 mediated stimulation of nuclear factor κB and IL-6, but not IL-1α and IL-8. H2O2 induced formation of cross-linked actin networks and stress fibers, which was reduced by preemptive application of omega-3. Omega-6, in contrast, had no protective effect on that, and even seemed to promote condensation. Based on the observed side effects of omega-6, omega-3 appears to be the more beneficial fatty acid in respect of prophylactic intake for prevention of a glaucomatous disease

Telomere Shortening Impairs Regeneration of the Olfactory Epithelium in Response to Injury but Not Under Homeostatic Conditions

Atrophy of the olfactory epithelium (OE) associated with impaired olfaction and dry nose represents one of the most common phenotypes of human aging. Impairment in regeneration of a functional olfactory epithelium can also occur in response to injury due to infection or nasal surgery. These complications occur more frequently in aged patients. Although age is the most unifying risk factor for atrophic changes and functional decline of the olfactory epithelium, little is known about molecular mechanisms that could influence maintenance and repair of the olfactory epithelium. Here, we analyzed the influence of telomere shortening (a basic mechanism of cellular aging) on homeostasis and regenerative reserve in response to chemical induced injury of the OE in late generation telomere knockout mice (G3 mTerc−/−) with short telomeres compared to wild type mice (mTerc+/+) with long telomeres. The study revealed no significant influence of telomere shortening on homeostatic maintenance of the OE during mouse aging. In contrast, the regenerative response to chemical induced injury of the OE was significantly impaired in G3 mTerc−/− mice compared to mTerc+/+ mice. Seven days after chemical induced damage, G3 mTerc−/− mice exhibited significantly enlarged areas of persisting atrophy compared to mTerc+/+ mice (p = 0.031). Telomere dysfunction was associated with impairments in cell proliferation in the regenerating epithelium. Deletion of the cell cycle inhibitor, Cdkn1a (p21) rescued defects in OE regeneration in telomere dysfunctional mice. Together, these data indicate that telomere shortening impairs the regenerative capacity of the OE by impairing cell cycle progression in a p21-dependent manner. These findings could be relevant for the impairment in OE function in elderly people

Common genetic determinants of intraocular pressure and primary open-angle Glaucoma

10.1371/journal.pgen.1002611PLoS Genetics85

Ageing, neurodegeneration, and olfactory and gustatory loss

Olfactory and gustatory disorders increase with advancing age. Moreover, olfactory disorders are common in neurodegenerative disorders, especially in idiopathic Parkinson's disease (IPD) and Alzheimer's Disease (AD). Since the decrease in olfactory function is usually gradual, it often remains undetected. Given the poor self-assessment of olfactory function, olfactory testing is mandatory in suspected cases to establish the diagnosis of hyposmia or anosmia. The high rate of anosmia over the age of 70 is suspected to be due to several factors such as changes in the olfactory epithelium (reduced mucus secretion, hormonal changes, changes in epithelial thickness, for example), and the reduced neuroregeneration rate in olfactory receptor cells themselves. There is no known adequate treatment for stopping or reversing this age-related decline in olfaction. In IPD, olfactory impairment precedes motor symptoms by years and is independent of dopaminergic loss. Using fMRI, altered neuronal activity in the amygdaloid complex and hippocampal formation during olfactory stimulation have been demonstrated, as has a link between the expression of olfactory event-related potentials and olfactory-induced brain activity. In AD--by contrast with IPD--the severity of the disease and the olfactory disorder correlate. The olfactory disorders alone, however, cannot distinguish between AD and IPD. A complete loss of gustatory function is rare, while dysgeusia is common, especially with increasing age. There are multiple possible explanations, including concomitant disease and the side-effects of medication. These need to be established on the basis of exact history and examination. Treatment remains difficult

an overview of available therapies

The incidence of olfactory disorders is appoximately 1-2% and they can seriously impact on the quality of life. Quantitative disorders (hyposmia, anosmia) are distinguished from qualitative disorders (parosmia, phantosmia). Olfactory disorders are classified according to the etiology and therapy is planned according to the underlying pathophysiology. In ENT patients olfactory disorders caused by sinonasal diseases are the most common ones, followed by postviral disorders. Therapy consists of topical and systemic steroids, whereas systemic application seems to be of greater value. It is very difficult to predict the improvement of olfactory function using surgery, moreover, the long term - success in surgery is questionable. Isolated taste disorders are rare and in most often caused by underlying diseases or side effects of medications. A meticulous history is necessary and helps to choose effective treatment. In selected cases zinc might be useful