[Covid-19 Pandemic: Anxiety Experience of Resident and Hospital Psychiatrists]. / Covid-19-Pandemie: Angsterleben von niedergelassenen und Krankenhaus-Psychiatern.

BACKGROUND: To date, no studies have examined the pandemic-related stress experience of inpatient versus outpatient psychiatrists. Therefore, the aim is to investigate the extent of Covid-19 exposure, anxiety, stress experience, and coping abilities among psychiatrists in private practice compared to physicians in psychiatric and psychosomatic hospitals. METHODS: E-mail-based questionnaires with 13 items were used to assess anxiety and stress experience. A total of 105 practicing psychiatrists, and 73 physicians and psychologists from four clinics (including the Clinic for Psychosomatic Medicine and Psychotherapy) were surveyed between early April and mid-May 2020. RESULTS: Compared to hospital psychiatrists, psychiatrists in private practice more often felt severely restricted (52.4 vs. 32.9% p=0.010), at risk of infection (35.2 vs. 13.7%, p<0.001) and financially threatened (24.7 vs. 6.9%, p=0.002). The proportion of well-informed practicing psychiatrists was lower (47.6 vs. 63.0%, p=0.043) and the proportion with lack of protective equipment was higher (27.6 vs. 4.1%, p<0.001). At the same COVID-19 exposure level (8.6 vs. 8.2%), office-based psychiatrists were more likely to report high anxiety, although not significantly, compared to hospital psychiatrists (18.1 vs. 9.6%, p=0.114). Risk factors for experiencing anxiety in both groups were feeling restricted (OR=5.52, p=0.025) and experienced risk of infection (OR=5.74, p=0.005). Exposure level, clinic or practice affiliation, age, gender, and other dimensions of threat experience and coping behavior had no influence. DISCUSSION: Psychiatrists in private practice felt more stressed and threatened by the COVID-19 pandemic compared with hospital-based colleagues. The experience of anxiety was dependent on feeling constrained and at risk of exposure, but not on exposure, protective equipment. Objective indicators seem to play less of an important role in the expression of anxiety than subjective experience.

Vestibular Migraine: Treatment and Prognosis.

Treatment of vestibular migraine currently lacks a firm scientific basis, as high quality randomized controlled trials are not available. Therefore, recommendations are largely borrowed from the migraine sphere. The first therapeutic step is explanation and reassurance. Many patients do not need pharmacological treatment, as attacks may be infrequent and tolerable. Acute attacks can be ameliorated in some patients with antiemetic drugs such as diphenhydramine, meclizine, and metoclopramide. Frequent attacks may warrant pharmacological prophylaxis with metoprolol, amitriptyline, topiramate, valproic acid, or flunarizine. Nonpharmacological measures including regular exercise, relaxation techniques, stress management, and biofeedback may be similarly effective and can be combined with a pharmacological approach. Limited data indicate that the prognosis appears to be less favorable for vestibular migraine than for migraine headaches.

Management of financial conflicts of interests in clinical practice guidelines in Germany: results from the public database GuidelineWatch.

BACKGROUND: The reliability of clinical practice guidelines has been disputed because guideline panel members are often burdened with financial conflicts of interest (COI). Current recommendations for COI regulation advise not only detailed declaration but also active management of conflicts. To continuously assess COI declaration and management in German guidelines we established the public database LeitlinienWatch (GuidelineWatch). METHODS: We analyzed all German guidelines at the highest methodological level (S3) that included recommendations for pharmacological therapy (n = 67) according to five criteria: declaration and assessment of COI, composition of the guideline development group, independence of the coordinators and lead authors, imposed abstentions because of COI and public external review. Each criterion was assessed using predefined outcome categories. RESULTS: Most guidelines (76%) contained a detailed declaration of COI. However, none of the guidelines provided full transparency of COI assessment results. The guideline group was composed of a majority of participants with COI in 55% of the guidelines, no guideline was free of participants with COI. Only 9% of guidelines had coordinators and lead authors without any financial COI. Most guidelines (70%) did not provide a rule for abstentions for participants with COI. In 21% of guidelines there was a rule, but abstentions were either not practiced or not documented, whereas in 7% partial abstentions and in 2% complete abstentions were documented. Two thirds of the guideline drafts (67%) were not externally reviewed via a public website. CONCLUSIONS: COI are usually documented in detail in German guidelines of the highest methodological level. However, considerable improvement is needed regarding active management of COI, including recruitment of independent experts for guideline projects, abstention from voting for participants with COI and external review of the guideline draft. We assume that the publicly available ratings on GuidelineWatch will improve the handling of conflicts of interest in guideline development.

Vestibular migraine.

Vestibular migraine presents with attacks of spontaneous or positional vertigo, head motion-induced vertigo, and visual vertigo lasting 5 minutes to 3 days. The recent classification of vestibular migraine, jointly proposed by the Bárány Society and the International Headache Society, allows identification of vestibular migraine and probable vestibular migraine based on explicit criteria. The diagnosis is based on symptom type, severity and duration, a history of migraine, temporal association of migraine symptoms with vertigo attacks, and exclusion of other causes. Because headache is often absent during acute attacks, other migraine features such as photophobia or auras have to be specifically inquired about. During acute attacks, one may find central spontaneous or positional nystagmus, and less commonly, unilateral vestibular hypofunction. In the symptom-free interval, vestibular testing adds little to the diagnosis as findings are mostly minor and nonspecific. The pathophysiology of vestibular migraine is unknown, but several mechanisms link the trigeminal system, which is activated during migraine attacks, and the vestibular system. Treatment includes antiemetics for severe acute attacks, pharmacological migraine prophylaxis, and lifestyle changes.

[COVID-19 and Anxiety Amongst General Practitioners, Psychiatrists and Surgeons - A German Perspective]. / Angsterleben von Hausärzten, Psychiatern und Chirurgen zu Beginn der COVID-19-Pandemie in Deutschland.

OBJECTIVE: The COVID-19 pandemic represents an exceptional challenge for the medical fraternity. We examined the differences in experiencing anxiety of general practitioners (GP), psychiatrists (PS) and surgeons (SU) during the COVID-19 pandemic in Germany. METHODS: E-mail-based survey (April-May 2020) of 608 physicians (GP n = 162, PS n = 299, SU n = 147) on anxiety experience in relation to COVID-19 and potential determinants. RESULTS: High levels of COVID-19-related anxiety were reported by 31.1 % of GP, 19.2 % of PS, and 11.6 % of SU. The frequency of contact with COVID-19 patients was highest in SU (68.5 %), followed by GP (51.0 %) and PS (8.1 %). The experience of COVID-19-related distress was overall highest among GP. SU felt best informed and rated their resilience most highly. A high level of anxiety was positively associated with the perceived risk of infection. CONCLUSION: Studies on the distress of physicians provide important information to optimize pandemic management.

Vestibular migraine: Diagnostic criteria1.

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). It contains a literature update while the original criteria from 2012 were left unchanged. The classification defines vestibular migraine and probable vestibular migraine. Vestibular migraine was included in the appendix of the third edition of the International Classification of Headache Disorders (ICHD-3, 2013 and 2018) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

The Bárány Society position on 'Cervical Dizziness'.

This paper describes the Bárány Society Classification OverSight Committee (COSC) position on Cervical Dizziness, sometimes referred to as Cervical Vertigo. This involved an initial review by a group of experts across a broad range of fields, and then subsequent review by the Bárány Society COSC. Based upon the so far published literature, the Bárány Society COSC takes the view that the evidence supporting a mechanistic link between an illusory sensation of self-motion (i.e. vertigo - spinning or otherwise) and neck pathology and/or symptoms of neck pain - either by affecting the cervical vertebrae, soft tissue structures or cervical nerve roots - is lacking. When a combined head and neck movement triggers an illusory sensation of spinning, there is either an underlying common vestibular condition such as migraine or BPPV or less commonly a central vestibular condition including, when acute in onset, dangerous conditions (e.g. a dissection of the vertebral artery with posterior circulation stroke and, exceedingly rarely, a vertebral artery compression syndrome). The Committee notes, that migraine, including vestibular migraine, is by far, the commonest cause for the combination of neck pain and vestibular symptoms. The committee also notes that since head movement aggravates symptoms in almost any vestibular condition, the common finding of increased neck muscle tension in vestibular patients, may be linked as both cause and effect, to reduced head movements. Additionally, there are theoretical mechanisms, which have not been explored, whereby cervical pain may promote vaso-vagal, cardio-inhibitory reflexes and hence by presyncopal mechanisms, elicit   transient   disorientation and/or imbalance. The committee accepts that further research is required to answer the question as to whether those rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation and/or imbalance, is indeed linked to impaired neck proprioception. Future studies should ideally be placebo controlled and double-blinded where possible, with strict inclusion and exclusion criteria that aim for high specificity at the cost of sensitivity. To facilitate further studies in "cervical dizziness/vertigo", we provide a narrative view of the important confounds investigators should consider when designing controlled mechanistic and therapeutic studies. Hence, currently, the Bárány COSC refrains from proposing any preliminary diagnostic criteria for clinical use outside a research study. This position may change as new research evidence is provided.

Vestibular migraine--validity of clinical diagnostic criteria.

BACKGROUND: Clinical recognition of vestibular migraine (VM) is still hampered by the lack of consensus diagnostic criteria. The aim of this study is a long-term evaluation of clinical criteria for definite (dVM) and probable (pVM) vestibular migraine. METHODS: We re-assessed 75 patients (67 women, age 24-76 years) with dVM (n=47) or pVM (n=28) according to previously published criteria after a mean follow-up of 8.75±1.3 years. Assessment included a comprehensive neurotological clinical examination, pure tone audiometry and caloric testing. RESULTS: dVM was confirmed in 40 of 47 patients with a prior diagnosis of dVM (85%). Fourteen of 28 patients initially classified as pVM met criteria for dVM (50%), nine for pVM (32%). Six additional patients with dVM and two with pVM had developed mild sensorineural hearing loss, formally fulfilling criteria for bilateral Menière's disease (MD), but had clinical features atypical of MD. Seven of these also met criteria for dVM at follow-up. The initial diagnosis was completely revised for four patients. CONCLUSION: Although VM diagnosis lacks a gold standard for evaluation of diagnostic criteria, repeated comprehensive neurotological evaluation after a long follow-up period indicates not only high reliability but also high validity of presented clinical criteria (positive predictive value 85%). Half of patients with pVM evolve to meet criteria for dVM. However, in a subgroup of VM patients with hearing loss, criteria for dVM and MD are not sufficiently discriminative.

Prevalence and complications of orthostatic dizziness in the general population.

Although orthostatic dizziness (OD) is a common complaint, its prevalence and medical impact in the general population are unknown. The study aims to assess prevalence, medical sequelae and healthcare and social impact of OD in the general population. Participants of the representative German National Health Interview Survey 2003 (n = 4077, age 18-89 years, response rate 52%) were screened for moderate or severe dizziness or vertigo. As part of a larger study on the epidemiology of dizziness and vertigo, a consecutive subsample of screen-positive participants (n = 825) underwent a structured medical interview for OD based on the criteria: (1) non-vestibular dizziness (i.e. diffuse non-rotational dizziness, light headedness, feeling of impeding faint), (2) provocation by sudden postural change (i.e. standing up from supine or sitting), (3) duration of seconds to several minutes, (4) absence of vestibular vertigo according to a validated neurotologic interview. The 12-month prevalence of OD was 10.9% (women 13.1%, men 8.2%), lifetime prevalence was 12.5% (women 15.0%, men 9.6%). OD accounted for 42% of all participants with dizziness/vertigo and for 55% of non-vestibular dizziness diagnoses. The prevalence of OD was highest in young people, although the proportion with severe OD steadily increased with age. OD led to syncope in 19%, falls in 17% and traumatic injury in 5% of affected subjects. Almost half of the individuals with OD (45%) had consulted a physician and 4% had been treated in hospital. OD is a frequent cause of non-vestibular dizziness for which patients often seek medical advice. It carries a considerable risk of syncope, falls and traumatic injury.

Recurrent Vestibular Symptoms Not Otherwise Specified: Clinical Characteristics Compared With Vestibular Migraine and Menière's Disease.

Despite the huge progress in the definition and classification of vestibular disorders within the last decade, there are still patients whose recurrent vestibular symptoms cannot be attributed to any of the recognized episodic vestibular syndromes, such as Menière's disease (MD), vestibular migraine (VM), benign paroxysmal positional vertigo (BPPV), vestibular paroxysmia, orthostatic vertigo or transient ischemic attack (TIA). The aim of the present international, multi-center, cross-sectional study was to systematically characterize the clinical picture of recurrent vestibular symptoms not otherwise specified (RVS-NOS) and to compare it to MD and VM. Thirty-five patients with RVS-NOS, 150 patients with VM or probable VM and 119 patients with MD were included in the study. The symptoms of RVS-NOS had been present for 5.4 years on average before inclusion, similar to VM and MD in this study, suggesting that RVS-NOS is not a transitory state before converting into another diagnosis. Overall, the profile of RVS-NOS vestibular symptoms was more similar to VM than MD. In particular, the spectrum of vestibular symptom types was larger in VM and RVS-NOS than in MD, both at group comparison and the individual level. However, in contrast to VM, no female preponderance was observed for RVS-NOS. Positional, head-motion and orthostatic vertigo were reported more frequently by patients with RVS-NOS than MD, while external vertigo was more prevalent in the MD group. At group level, the spectrum of attack durations from minutes to 3 days was evenly distributed for VM, while a small peak for short and long attacks in RVS-NOS and a big single peak of hours in MD were discernible. In general, vertigo attacks and associated vegetative symptoms (nausea and vomiting) were milder in RVS-NOS than in the other two disorders. Some patients with RVS-NOS described accompanying auditory symptoms (tinnitus: 2.9%, aural fullness and hearing loss: 5.7% each), migrainous symptoms (photophobia, phonophobia or visual aura in 5.7% each) or non-migrainous headaches (14%), but did not fulfill the diagnostic criteria for MD or VM. Absence of a life time diagnosis of migraine headache and attack duration of <5 min were further reasons not to qualify for VM. In some RVS-NOS patients with accompanying ear symptoms, attack durations of <20 min excluded them from being diagnosed with MD. These findings suggest that RVS-NOS is a stable diagnosis over time whose overall clinical presentation is more similar to VM than to MD. It is more likely to be composed of several disorders including a spectrum of mild or incomplete variants of known vestibular disorders, such as VM and MD, rather than a single disease entity with distinct pathognomonic features.

Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society.

This paper describes the diagnostic criteria for "Vestibular Migraine of Childhood", "probable Vestibular Migraine of Childhood" and "Recurrent Vertigo of Childhood" as put forth by the Committee for the Classification of Vestibular Disorders of the Bárány Society (ICVD) and the Migraine Classification subgroup of the International Headache Society. Migraine plays an important role in some subgroups of children with recurrent vertigo. In this classification paper a spectrum of three disorders is described in which the migraine component varies from definite to possibly absent. These three disorders are: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. The criteria for Vestibular Migraine of Childhood (VMC) include (A) at least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, (B) a current or past history of migraine with or without aura, and (C) at least half of episodes are associated with at least one migraine feature. Probable Vestibular Migraine of Childhood (probable VMC) is considered when at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, are accompanied by at least criterion B or C from the VMC criteria. Recurrent Vertigo of Childhood (RVC) is diagnosed in case of at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours, and none of the criteria B and C for VMC are applicable. For all disorders, the age of the individual needs to be below 18 years old. It is recommended that future research should particularly focus on RVC, in order to investigate and identify possible subtypes and its links or its absence thereof with migraine.

Diagnostic accuracy of a smartphone bedside test to assess the fixation suppression of the vestibulo-ocular reflex: when nothing else matters.

OBJECTIVE: Validation of a bedside test to objectify the fixation suppression of the vestibulo-ocular reflex (FS-VOR) in patients with a cerebellar syndrome and healthy controls. METHODS: The vestibulo-ocular reflex and its fixation suppression were assessed by video-nystagmography (VNG) in 20 healthy subjects (mean age 56 ± 15) and 19 patients with a cerebellar syndrome (mean age 70 ± 11). The statistical cutoff delineating normal from pathological FS-VOR was determined at the 2.5th percentile of the normal distribution of the healthy cohort. VNG was then compared to a bedside test, where eye movements were recorded with a smartphone while patients were rotated on a swivel chair at a defined speed and amplitude. These videos were rated as normal or pathological FS-VOR by six blinded raters, and results compared to VNG. RESULTS: VNG in healthy controls showed FS-VOR with a reduction of nystagmus beats by 95.0% ± 7.2 (mean ± SD). The statistical cutoff was set at 80.6%. Cerebellar patients reduced nystagmus beats by only 26.3% ± 25.1. Inter-rater agreement of the smartphone video ratings was 85%. The sensitivity of the video ratings to detect an impaired FS-VOR was 99%, its specificity 92%. Inter-test agreement was 91%. CONCLUSION: The smartphone bedside test is an easily performed, reliable, sensitive, specific, and inexpensive alternative for assessing FS-VOR.

Correction to: Diagnostic accuracy of a smartphone bedside test to assess the fixation suppression of the vestibulo­ocular reflex: when nothing else matters.

The article Diagnostic accuracy of a smartphone bedside test to assess the fixation suppression of the vestibulo­ocular reflex: when nothing else matters, written by Florin Gandor, Manfred Tesch, Hannelore Neuhauser, Doreen Gruber, Hans­Jochen Heinze, Georg Ebersbach and Thomas Lempert, was originally published electronically on the publisher's internet portal on 01 June 2020 without open access.

Vertigo: epidemiologic aspects.

Vertigo is a frequent symptom in the general population with a 12-month prevalence of 5% and an incidence of 1.4% in adults. Its prevalence rises with age and is about two to three times higher in women than in men. The epidemiology of vertigo and underlying specific vestibular disorders is still an underdeveloped field despite its usefulness for clinical decision making and its potential for improving patient care. In this article, the authors give an overview on the epidemiology of vertigo as a symptom and of four specific vestibular disorders: benign paroxysmal positional vertigo (BPPV), vestibular migraine, Ménière's disease, and vestibular neuritis.

Vestibular Migraine.

The term vestibular migraine designates recurrent vertigo that is caused by migraine. Vestibular migraine presents with episodes of spontaneous or positional vertigo lasting seconds to days that are accompanied by migraine symptoms. Because headache is often absent during acute attacks, other migraine features have to be identified by thorough history taking. In contrast, vestibular testing serves mainly for the exclusion of other diagnoses. Treatment still lacks solid evidence. It is targeted at the underlying migraine and comprises explanation and reassurance, lifestyle modifications, and drugs.

Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria.

This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.

Acute migrainous vertigo: clinical and oculographic findings.

Migrainous vertigo (MV) is an increasingly recognized cause of episodic vertigo. However, the pathophysiology of MV is still a matter of speculation and it is not known to what extent the dysfunction is located in the central or peripheral vestibular system. The aim of this prospective study was to describe the clinical spectrum of acute MV and to clarify which structures of the vestibular system are involved. Testing of 20 patients with acute MV included neuro-otological examination, recording of spontaneous and positional nystagmus with 3D video-oculography, and audiometry. Pathological nystagmus was observed in 70% of patients during acute MV: six had isolated spontaneous nystagmus, five had isolated positional nystagmus and three had a combination of the two. Only a few patients showed additional ocular motor deficits. Imbalance was observed in all patients except one. Hearing was not affected in any patient during the attack. The findings during acute MV point to central-vestibular dysfunction in 10 patients (50%) and to peripheral vestibular dysfunction in three patients (15%). In the remaining seven patients (35%) the site of involvement could not be determined with certainty. MV should be considered in the differential diagnosis of vertigo with spontaneous and positional nystagmus and can present both as a central and a peripheral vestibular disorder.

Utricular dysfunction in patients with benign paroxysmal positional vertigo.

OBJECTIVE: The objective of this study was to test the hypothesis that utricular function is impaired in patients with idiopathic benign paroxysmal positional vertigo. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary dizziness clinic and vestibular research laboratory. PATIENTS: Twelve patients with unilateral idiopathic benign paroxysmal positional vertigo were examined 1 week and 1 month after successful treatment with positioning maneuvers and compared with 24 healthy subjects. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Otolith function was assessed with estimation of the subjective visual vertical and analysis of the torsional otolith-ocular reflex. Unilateral stimulation of the utricle was performed on a rotator that allowed eccentric lateral displacement of the patient during earth-vertical rotation with constant velocity. The otolith-ocular reflex was recorded with three-dimensional video-oculography. RESULTS: There was no difference in the estimation of the subjective visual vertical between patients and controls. The peak-to-peak amplitude of the otolith-ocular reflex torsional eye position was smaller in patients than in the control group. The gain of the unilateral otolith-ocular reflex was reduced in patients on both sides on first testing. After several weeks, only the affected labyrinth showed a reduced otolith-ocular reflex gain. CONCLUSION: Our findings document otolith dysfunction in patients with idiopathic benign paroxysmal positional vertigo possibly secondary to degeneration of the utricular macula. This finding may account for the transient mild imbalance and dizziness that some patients with benign paroxysmal positional vertigo experience even after resolution of positional vertigo.