Remote assessment and management of patients with dizziness: development, validation, and feasibility of a gamified vestibular rehabilitation therapy platform.

Introduction: Dizziness is a growing public health concern with as many as 95 million adults in Europe and the United States experiencing vestibular hypofunction, which is associated with reduced quality of life, poorer health, and falls. Vestibular rehabilitation therapy (VRT) is effective in reducing symptoms and improving balance; however, limited access to qualified clinicians and poor patient adherence impedes optimal delivery. The goal of this study was to develop and evaluate the feasibility of a remote therapeutic monitoring VRT Platform application (APP) for the assessment and treatment of vestibular dysfunction. Methods: User-centered iterative design process was used to gather and integrate the needs of users (clinicians and patients) into the design at each stage of development. Commonly used vestibular patient-reported outcome measures (PROs) were integrated into the APP and adults with chronic dizziness were enrolled to evaluate validity and reliability of the APP compared to standard clinical measures (CLIN). Gaze stabilization exercises were gamified to provide an engaging experience and an off-the-shelf sensor captured eye and head movement to provide feedback on accuracy of performance. A prospective, pilot study design with pre-and post-treatment assessment assessed feasibility of the APP compared to standard VRT (CLIN). Results: Participants with dizziness wanted a summary rehabilitation report shared with their clinicians, felt that an app could help with accountability, and believed that a gaming format might help with exercise adherence. Clinicians felt that the app should include features to record and track eye and head movement, monitor symptoms, score accuracy of task performance, and measure adherence. Validity and reliability of the digital PROs (APP) were compared to scores from CLIN across two sessions and found to have good validity, good to excellent test-retest reliability, and excellent usability (≥88%ile). The pilot study demonstrated feasibility for use of the APP compared to CLIN for treatment of vestibular hypofunction. The mean standard system usability score of the APP was 82.5 indicating excellent usability. Discussion: Both adult patients with chronic dizziness and VRT clinicians were receptive to the use of technology for VRT. The HiM-V APP is a feasible alternative to clinical management of adults with chronic peripheral vestibular hypofunction.

Gentrification drives patterns of alpha and beta diversity in cities.

While there is increasing recognition that social processes in cities like gentrification have ecological consequences, we lack nuanced understanding of the ways gentrification affects urban biodiversity. We analyzed a large camera trap dataset of mammals (>500 g) to evaluate how gentrification impacts species richness and community composition across 23 US cities. After controlling for the negative effect of impervious cover, gentrified parts of cities had the highest mammal species richness. Change in community composition was associated with gentrification in a few cities, which were mostly located along the West Coast. At the species level, roughly half (11 of 21 mammals) had higher occupancy in gentrified parts of a city, especially when impervious cover was low. Our results indicate that the impacts of gentrification extend to nonhuman animals, which provides further evidence that some aspects of nature in cities, such as wildlife, are chronically inaccessible to marginalized human populations.

Effectiveness of Vestibular Rehabilitation for Patients with Degenerative Cerebellar Ataxia: A Retrospective Cohort Study.

Many patients with cerebellar ataxia have dizziness caused by oculomotor or peripheral vestibular deficits; however, there is little evidence supporting the use of vestibular rehabilitation for this population. The purpose of this study was to determine whether patients with degenerative cerebellar diseases improve following rehabilitation including vestibular exercises. A secondary aim was to identify variables associated with the outcomes. A retrospective chart review identified 42 ambulatory patients (23 men and 19 women; mean age = 54.5 ± 14.4 years) with cerebellar degeneration. Fourteen patients had ataxia only, twenty had ataxia and oculomotor abnormalities, and eight had ataxia with oculomotor and peripheral vestibular deficits. Patients received customized physical therapy including balance and gait training, as well as gaze stabilization and habituation exercises for vestibular hypofunction and motion-provoked dizziness. Primary outcome measures (Activities-specific Balance Confidence Scale, Tinetti Performance Oriented Mobility Assessment, Dynamic Gait index, and Sensory Organization Test) were evaluated at baseline and discharge. Patients improved (p < 0.05) on all outcome measures. Patients with vestibular deficits were seen for more visits compared to those with gait ataxia only (7.1 vs. 4.8 visits). This study provides evidence that patients with degenerative cerebellar disease improve in balance confidence, fall risk and sensory integration with therapy that includes vestibular rehabilitation.

Type, dose, and outcomes of physical therapy interventions for unilateral peripheral vestibular hypofunction: protocol for a systematic review.

BACKGROUND: Unilateral peripheral vestibular hypofunction can result in symptoms of dizziness, gaze and gait instability, and impaired navigation and spatial orientation. These impairments and activity limitations may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. However, there is great variability in clinical practice with regard to the type of interventions and only weak evidence to guide optimal exercise dosage. It is important to identify the most appropriate interventions and exercise dosage to optimize and accelerate recovery of function and to decrease distress. The objective of this systematic review is to determine which interventions and which doses are most effective in decreasing dizziness or vertigo, improving postural control, and improving quality of life in adults with unilateral peripheral vestibular hypofunction. METHODS: The literature will be systematically searched using the following online databases: PubMed/MEDLINE, EMBASE, Web of Science (Science and Social Science Citation Index), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). The review will include randomized controlled trials (RCTs), including cluster RCTs, to assess the beneficial effects of the interventions. Assessment of methodological quality and risk of bias will be performed by two independent, blinded reviewers using the PEDro scale and Cochrane Risk of Bias version 2, respectively. The primary outcome measure will be change in self-perceived handicap related to dizziness from baseline to the end of the study, measured using the Dizziness Handicap Inventory. Other relevant outcome measures will include self-reported change in symptoms (to include severity, frequency, and duration) such as verbal or visual analog scales for dizziness. Tertiary outcome measures will include questionnaires related to disability and/or quality of life. DISCUSSION: This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for unilateral peripheral vestibular hypofunction in an adult population. We anticipate our findings may inform individualized treatment and future research. Clinical recommendations generated from this systematic review may inform vestibular physical therapy treatment of individuals with unilateral peripheral vestibular hypofunction. TRIAL REGISTRATION: In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 06 August 2021 (registration number CRD42021266163 ). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Factors That Impact the Long-Term Outcome of Postconcussive Dizziness Among Post-9/11 Veterans.

PURPOSE: The primary aim of this study was to examine the factors associated with long-term outcomes of postconcussive disruptive dizziness in Veterans of the post-9/11 wars. METHOD: For this observational cohort study, the Neurobehavioral Symptom Inventory-Vestibular subscale (NSI-V) score was used as an outcome measure for dizziness in 987 post-9/11 Veterans who indicated disruptive dizziness at an initial Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation (CTBIE). An NSI-V change score was calculated as the difference in the scores obtained at the initial CTBIE and on a subsequent survey. Differences in the NSI-V change scores were examined for demographics, injury characteristics, comorbidities, and vestibular and balance function variables, and multiple linear regression analyses were used to explore associations among the variables and the NSI-V change score. RESULTS: The majority of Veterans (61%) demonstrated a decrease in the NSI-V score, suggesting less dizziness on the survey compared with the CTBIE; 16% showed no change; and 22% had a higher score. Significant differences in the NSI-V change score were observed for traumatic brain injury (TBI) status, diagnoses of post-traumatic stress disorder (PTSD), headache and insomnia, and vestibular function. Multivariate regressions revealed significant associations between the NSI-V change score and the initial CTBIE NSI-V score, education level, race/ethnicity, TBI status, diagnoses of PTSD or hearing loss, and vestibular function. CONCLUSIONS: Postconcussive dizziness can continue for years following an injury. Factors associated with poor prognosis include TBI, diagnoses of PTSD or hearing loss, abnormal vestibular function, increased age, identification as a Black Veteran, and high school education level.

Hypermethylation at CREBBP Is Associated with Cognitive Impairment in a Mexican American Cohort.

BACKGROUND: The aging Mexican American (MA) population is the fastest growing ethnic minority group in the US. MAs have a unique metabolic-related risk for Alzheimer's disease (AD) and mild cognitive impairment (MCI), compared to non-Hispanic whites (NHW). This risk for cognitive impairment (CI) is multifactorial involving genetics, environmental, and lifestyle factors. Changes in environment and lifestyle can alter patterns and even possibly reverse derangement of DNA methylation (a form of epigenetic regulation). OBJECTIVE: We sought to identify ethnicity-specific DNA methylation profiles that may be associated with CI in MAs and NHWs. METHODS: DNA obtained from peripheral blood of 551 participants from the Texas Alzheimer's Research and Care Consortium was typed on the Illumina Infinium® MethylationEPIC chip array, which assesses over 850K CpG genomic sites. Within each ethnic group (N = 299 MAs, N = 252 NHWs), participants were stratified by cognitive status (control versus CI). Beta values, representing relative degree of methylation, were normalized using the Beta MIxture Quantile dilation method and assessed for differential methylation using the Chip Analysis Methylation Pipeline (ChAMP), limma and cate packages in R. RESULTS: Two differentially methylated sites were significant: cg13135255 (MAs) and cg27002303 (NHWs) based on an FDR p < 0.05. Three suggestive sites obtained were cg01887506 (MAs) and cg10607142 and cg13529380 (NHWs). Most methylation sites were hypermethylated in CI compared to controls, except cg13529380 which was hypomethylated. CONCLUSION: The strongest association with CI was at cg13135255 (FDR-adjusted p = 0.029 in MAs), within the CREBBP gene. Moving forward, identifying additional ethnicity-specific methylation sites may be useful to discern CI risk in MAs.

Vestibular and balance function in veterans with chronic dizziness associated with mild traumatic brain injury and blast exposure.

The purpose of this study was to examine vestibular and balance function in individuals with chronic dizziness associated with mTBI/blast. A prospective case-control study design was used to examine ocular motor, vestibular function, and postural stability in veterans with symptoms of dizziness and/or imbalance following an mTBI or blast exposure (n = 77) and a healthy control group (n = 32). Significant group differences were observed for saccadic accuracy, VOR gain during slow harmonic acceleration at 0.01 Hz, cervical vestibular evoked myogenic potentials asymmetry ratio, composite equilibrium score on the sensory organization test, total Dynamic Gait Index score, and gait. The frequency of test abnormalities in participants with mTBI/blast ranged from 0 to 70% across vestibular, ocular motor, and balance/gait testing, with the most frequent abnormalities occurring on tests of balance and gait function. Seventy-two percent of the mTBI/blast participants had abnormal findings on one or more of the balance and gait tests. Vestibular test abnormalities occurred in ~34% of the individuals with chronic dizziness and mTBI/blast, and abnormalities occurred more frequently for measures of otolith organ function (25% for cVEMP and 18% for oVEMP) than for measures of hSCC function (8% for SHA and 6% for caloric test). Abnormal ocular motor function occurred in 18% of the mTBI/blast group. These findings support the need for comprehensive vestibular and balance assessment in individuals with dizziness following mTBI/blast-related injury.

Development and Validation of the Modified Motion Sensitivity Test.

OBJECTIVE: The aim of this study was to develop and validate an outcome measure for individuals with motion-provoked dizziness. STUDY DESIGN: Methodological. SETTING: Academic outpatient vestibular and dizziness clinic. PATIENTS/SUBJECTS: Adults with and without motion-provoked dizziness. MAIN OUTCOME MEASURES: Scores from the modified Motion Sensitivity Test (mMST) were compared between those with motion-provoked dizziness and controls without complaints of dizziness to evaluate the validity of the mMST. Intrarater and interrater reliability of the total Motion Sensitivity Quotient scores were assessed. Baseline and discharge total Motion Sensitivity Quotient scores were collected in a group of patients to determine the sensitivity of the mMST to measure change in motion-provoked dizziness after vestibular rehabilitation. RESULTS: A 10-item motion sensitivity test was developed and demonstrated discriminant validity to differentiate patients with motion-provoked dizziness and control subjects without dizziness and demonstrated construct validity compared with the Dizziness Handicap Inventory (r = 0.64, p < 0.001). Internal validity of the mMST was excellent (Cronbach α = 0.95). The mMST demonstrated excellent reliability between raters (intraclass correlation coefficient = 1.00) and test sessions (intraclass correlation coefficient = 0.95). CONCLUSIONS: The results indicated that the mMST can be used reliably in clinical practice to develop exercise programs for patients with motion-provoked dizziness and to provide evidence of intervention efficacy. mMST is a valid, reliable measure to use in the clinic for patients with motion-provoked dizziness.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association.

BACKGROUND: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. METHODS: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. RESULTS: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes. DISCUSSION: Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction. LIMITATIONS: The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction. DISCLAIMER: These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Comparison of pharmacists' scoring of fall risk to other fall risk assessments.

OBJECTIVES: Given their professional education and participation within the health care system, pharmacists are ideal candidates to assess drug-associated fall risk for patients. The purpose of this investigation was to determine whether pharmacists can quantitatively differentiate individuals who reported falling within the previous year (fallers) from those who do not (nonfallers), and to compare the pharmacists' evaluation with 2 recently published fall risk assessments. DESIGN: Cross-sectional design of pharmacists' assessments of fall risk. SETTING AND PARTICIPANTS: This is a cross-sectional study where 6 licensed pharmacists evaluated patient records from Wave 1 of the National Social Life, Health and Aging Project dataset using generic drug list (drug counts), age, and body mass index to generate a Pharmacist Risk Score (PRS) based on these variables. Pharmacists were allowed to use drug information resources and were provided with a simple 5-point scale to assist them in scoring patients. OUTCOME MEASURES: The main outcome measure of this study was a comparison of the following fall risk assessments (PRS, drug counts, Medication-Based Index of Physical Function, Quantitative Drug Index, and Timed Up and Go [TUG]) capacity to differentiate fallers from nonfallers. RESULTS: Each fall risk assessment was highly correlated (P < 0.001) with the number of reported falls. Drug-associated fall risk assessments were highly correlated (P < 0.001) with each other, but not with TUG. Each fall risk assessment differentiated fallers from nonfallers based on logistic regression (P ≤ 0.001). Receiver operating characteristic (ROC) curve analysis was significant (P ≤ 0.002) for each assessment. The comparison of ROC area under the curve for the fall risk assessments found no significant difference between the PRS and other assessments. CONCLUSION: Fall risk assessment by pharmacists was comparable with other fall risk assessments in distinguishing fallers from nonfallers.

Accurate profiling of forensic autosomal STRs using the Oxford Nanopore Technologies MinION device.

The high variability characteristic of short tandem repeat (STR) markers is harnessed for human identification in forensic genetic analyses. Despite the power and reliability of current typing techniques, sequence-level information both within and around STRs are masked in the length-based profiles generated. Forensic STR typing using next generation sequencing (NGS) has therefore gained attention as an alternative to traditional capillary electrophoresis (CE) approaches. In this proof-of-principle study, we evaluate the forensic applicability of the newest and smallest NGS platform available - the Oxford Nanopore Technologies (ONT) MinION device. Although nanopore sequencing on the handheld MinION offers numerous advantages, including low startup cost and on-site sample processing, the relatively high error rate and lack of forensic-specific analysis software has prevented accurate profiling across STR panels in previous studies. Here we present STRspy, a streamlined method capable of producing length- and sequence-based STR allele designations from noisy, error-prone third generation sequencing reads. To assess the capabilities of STRspy, seven reference samples (female: n = 2; male: n = 5) were amplified at 15 and 30 PCR cycles using the Promega PowerSeq 46GY System and sequenced on the ONT MinION device in triplicate. Basecalled reads were then processed with STRspy using a custom database containing alleles reported in the STRSeq BioProject NIST 1036 dataset. Resultant STR allele designations and flanking region single nucleotide polymorphism (SNP) calls were compared to the manufacturer-validated genotypes for each sample. STRspy generated robust and reliable genotypes across all autosomal STR loci amplified with 30 PCR cycles, achieving 100% concordance based on both length and sequence. Furthermore, we were able to identify flanking region SNPs in the 15-cycle dataset with > 90% accuracy. These results demonstrate that when analyzed with STRspy ONT reads can reveal additional variation in and around STR loci depending on read coverage. As the first and only third generation sequencing platform-specific method to successfully profile the entire panel of autosomal STRs amplified by a commercially available multiplex, STRspy significantly increases the feasibility of nanopore sequencing in forensic applications.

Treatment of Vestibular Disorders (Inner Ear Balance Problems): How Does Your Physical Therapist Treat Dizziness Related to Inner Ear Balance Problems?

Dizziness is very common, but it is never normal. Dizziness can make performing daily activities, work, and walking difficult. Inner ear balance problems can make people dizzy when they turn their head, which can cause problems during walking and make people more likely to fall. Most of the time dizziness is not from a life-threatening disease. Often, dizziness is related to a problem of the vestibular (or inner ear balance) system. Vestibular disorders can be caused by infections in the ear, problems with the immune system, medications that harm the inner ear, and rarely from diabetes or stroke because of a lack of blood flow to the inner ear. Stress, poor sleep, migraine headaches, overdoing some activities, and feeling anxious or sad can increase symptoms of dizziness. Updated guidelines for the treatment of inner ear disorders are published in this issue of the Journal of Neurologic Physical Therapy. The guideline recommends which exercises are best to treat the dizziness and balance problems commonly seen with an inner ear problem.

Visual function and mobility after multifocal versus monofocal intraocular lens implantation.

Clinical relevance: Mobility and fall risk may be important considerations in choosing between intraocular lenses.Background: Fall risk in older adults increases when wearing multifocal spectacles, but little is known about mobility among individuals with different types of intraocular lenses. This study compared visual function, fall risk and balance control following bilateral implantation of monofocal or multifocal intraocular lenses.Methods: This was a non-randomised, cross-sectional study involving adults with bilateral intraocular lenses. Participants completed questionnaires concerning physical functioning, fall history and balance-related confidence. Binocular visual acuity, contrast sensitivity (Pelli-Robson chart and computerized testing), depth perception and glare sensitivity were assessed. Physical performance measures included the Sensory Organization Test, preferred gait speed, Dynamic Gait Index and wayfinding in a virtual environment.Results: Fifteen participants (mean ± standard deviation, 67.1 ± 6.8 years) had monofocal intraocular lenses and 14 participants (68.1 ± 6.1 years) had multifocal intraocular lenses. Contrast sensitivity in the monofocal group was significantly better than that in the multifocal group (p = 0.02) at intermediate and high spatial frequencies. Contrast sensitivity of the monofocal group also was less affected by glare than the contrast sensitivity of the multifocal group, at an intermediate spatial frequency (p = 0.02). However, the multifocal group had significantly better Dynamic Gait Index scores (p = 0.04), even after controlling for perceived physical function.Conclusions: The participants with monofocal intraocular lenses generally had better contrast sensitivity than did those with multifocal intraocular lenses. However, the scores on a mobility test that is associated with fall risk were worse for those with monofocal lenses.

Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury.

OBJECTIVE: To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING: Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS: Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN: A cross-sectional, retrospective, observational study. MAIN MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS: Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS: Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.

Pulmonary arterial hypertension patients display normal kinetics of clot formation using thrombelastography.

Pulmonary arterial hypertension is characterized by endothelial dysfunction and microthrombi formation. The role of anticoagulation remains controversial, with studies demonstrating inconsistent effects on pulmonary arterial hypertension mortality. Clinical anticoagulation practices are currently heterogeneous, reflecting physician preference. This study uses thrombelastography and hematology markers to evaluate whether clot formation and fibrinolysis are abnormal in pulmonary arterial hypertension patients. Venous blood was collected from healthy volunteers (n = 20) and patients with pulmonary arterial hypertension (n = 20) on stable medical therapy for thrombelastography analysis. Individual thrombelastography parameters and a calculated coagulation index were used for comparison. In addition, hematologic markers, including fibrinogen, factor VIII activity, von Willebrand factor activity, von Willebrand factor antigen, and alpha2-antiplasmin, were measured in pulmonary arterial hypertension patients and compared to healthy volunteers. Between group differences were analyzed using t tests and linear mixed models, accounting for repeated measures when applicable. Although the degree of fibrinolysis (LY30) was significantly lower in pulmonary arterial hypertension patients compared to healthy volunteers (0.3% ± 0.6 versus 1.3% ± 1.1, p = 0.04), all values were within the normal reference range (0-8%). All other thrombelastography parameters were not significantly different between pulmonary arterial hypertension patients and healthy volunteers (p ≥ 0.15 for all). Similarly, alpha2-antiplasmin activity levels were higher in pulmonary arterial hypertension patients compared to healthy volunteers (103.7% ± 13.6 versus 82.6% ± 9.5, p < 0.0001), but all individual values were within the normal range (75-132%). There were no other significant differences in hematologic markers between pulmonary arterial hypertension patients and healthy volunteers (p ≥ 0.07 for all). Sub-group analysis comparing thrombelastography results in patients treated with or without prostacyclin pathway targeted therapies were also non-significant. In conclusion, treated pulmonary arterial hypertension patients do not demonstrate abnormal clotting kinetics or fibrinolysis by thrombelastography.

Comparison of two escalated enoxaparin dosing regimens for venous thromboembolism prophylaxis in obese hospitalized patients.

Standard fixed-dose enoxaparin dosing regimens may not provide adequate prophylaxis against venous thromboembolism among obese hospitalized patients. While several escalated doses have been shown to result in more frequent attainment of target anti-factor Xa levels than standard doses, few studies compare escalated doses to each other. In this prospective, multi-center trial, enoxaparin 0.5 mg/kg daily (weight-based dosing) and enoxaparin 40 mg twice daily were compared to determine if either dose resulted in more frequent attainment of anti-factor Xa levels within the goal range of 0.2-0.5 IU/mL. Eighty patients with a BMI ≥ 40 kg/m2 were enrolled. There was no difference in the percent of patients achieving goal anti-factor Xa levels (72.5% vs. 70.0%, respectively; p = 0.72). Patients were more likely to attain anti-factor Xa levels below goal range than above. No bleeding or thrombotic events occurred. Either weight-based or twice-daily escalated enoxaparin dosing regimens appear effective at achieving target anti-factor Xa levels among hospitalized patients, and no safety events were noted. Future studies are needed to determine the clinical significance of this result.

Effects of Noise Exposure on the Vestibular System: A Systematic Review.

Despite our understanding of the impact of noise-induced damage to the auditory system, much less is known about the impact of noise exposure on the vestibular system. In this article, we review the anatomical, physiological, and functional evidence for noise-induced damage to peripheral and central vestibular structures. Morphological studies in several animal models have demonstrated cellular damage throughout the peripheral vestibular system and particularly in the otolith organs; however, there is a paucity of data on the effect of noise exposure on human vestibular end organs. Physiological studies have corroborated morphological studies by demonstrating disruption across vestibular pathways with otolith-mediated pathways impacted more than semicircular canal-mediated pathways. Similar to the temporary threshold shifts observed in the auditory system, physiological studies in animals have suggested a capacity for recovery following noise-induced vestibular damage. Human studies have demonstrated that diminished sacculo-collic responses are related to the severity of noise-induced hearing loss, and dose-dependent vestibular deficits following noise exposure have been corroborated in animal models. Further work is needed to better understand the physiological and functional consequences of noise-induced vestibular impairment in animals and humans.

Relationship Between Corrective Saccades and Measures of Physical Function in Unilateral and Bilateral Vestibular Loss.

OBJECTIVES: Following the loss of vestibular function, some patients functionally improve and are minimally bothered by their loss of peripheral function while others remain more symptomatic and are unable to return to their activities of daily living. To date, the mechanisms for functional improvement remain poorly understood. The purpose of the present study was to examine the association between corrective saccades and measures of handicap, dynamic visual acuity, gait, and falls. DESIGN: A retrospective chart review was performed to identify patients who were diagnosed with unilateral or bilateral vestibular hypofunction and who also completed a baseline vestibular rehabilitation evaluation. A total of 82 patients with unilateral vestibular hypofunction and 17 patients with bilateral vestibular hypofunction were identified. The video head impulse test results for each patient were grouped based on the type of presenting saccades. Specifically, the saccade grouping included the following: (1) covert, (2) overt, or (3) a combination of both types of saccades. RESULTS: The results show that covert saccades are associated with better performance on measures of dynamic visual acuity, gait, and balance in patients with unilateral vestibular hypofunction. Patients exhibiting overt saccades or combination of both covert and overt saccades were more often found to have an abnormal gait speed and be characterized as being at risk for falls using the Dynamic Gait Index. We observed no differences in physical function for those patients with bilateral vestibular hypofunction as a function of saccade grouping. CONCLUSIONS: When comparing saccade groups (covert, overt, or combination of both), patients with unilateral vestibular hypofunction and covert saccades demonstrated better performance on standard baseline physical therapy measures of dynamic visual acuity and gait and balance. We did not observe any significant associations between saccade group and physical function in patients with bilateral vestibular hypofunction; however, additional studies are needed with adequate sample sizes. Our findings may suggest that corrective saccade latency in patients with unilateral vestibular hypofunction is related to measures of physical function. The extent to which saccade latency has the potential to be a useful target for vestibular rehabilitation is still to be determined and may be promising target to improve functional outcomes.

Factors Associated With Rehabilitation Outcomes in Patients With Unilateral Vestibular Hypofunction: A Prospective Cohort Study.

OBJECTIVE: The purpose of this study was to determine factors associated with rehabilitation outcomes following vestibular rehabilitation (VR). METHODS: In this prospective cohort study, 116 patients who completed at least 2 supervised sessions participated. Patient characteristics and comorbidities were recorded. Initial and discharge measures included symptom intensity, balance confidence, quality of life, percent of time symptoms interfere with life, perceived benefits of VR, gait speed, fall risk, visual acuity during head movement, and anxiety/depression. Intention-to-treat analyses were performed to determine outcomes at discharge. Bivariate correlations between independent (group characteristics and baseline measures) and dependent (discharge measures) variables were determined. Logistic regressions were performed to identify factors associated with whether a patient would have a normal score or meaningful change at discharge. RESULTS: There was a large effect of VR with significant improvement for the group as a whole on each outcome measure. For each outcome measure, most patients improved. Based on preliminary logistic regression, 2 patient characteristics were associated with outcome: number of therapy visits predicted meaningful improvement in gait speed, and falls after the onset of the unilateral vestibular hypofunction (UVH) predicted meaningful change in the percent of time symptoms interfered with life. Initial Activities-Specific Balance Confidence Scale (ABC) and Dynamic Gait Index scores predicted normal ABC scores at discharge, and initial ABC scores predicted recovery of Dynamic Gait Index scores. Preliminary prediction models were generated for balance confidence, impact of dizziness on life, dynamic visual acuity, gait speed, and fall risk. CONCLUSIONS: Therapists may use these findings for patient education or to determine the need for adjunct therapy, such as counseling. IMPACT: Not all people with UVH improve following VR, but there is little research examining why. This study looked at multiple factors and identified number of visits and falls after onset of UVH as patient characteristics associated with outcomes following VR; these findings will help therapists create better predictive models.

Impact of Interdisciplinary Team Care for Children With 22q11.2 Deletion Syndrome.

OBJECTIVE: To evaluate disease-specific guideline adherence among children with 22q11.2 deletion syndrome receiving multidisciplinary team care through a 22q specialty clinic compared to children not receiving team care. DESIGN: Retrospective chart review; quality improvement project. SETTING: Tertiary care pediatric hospital. PATIENTS: One hundred eighty-nine patients with 22q11.2 deletion syndrome were categorized into those receiving team care and those not receiving team care. Guideline adherence was compared between the 2 groups. MAIN OUTCOME MEASURE(S): Percent adherence across 8 disease-specific guidelines. RESULTS: A Welch t test revealed mean adherence among patients receiving team care was significantly higher (83% vs 42%, P < .001) compared those not receiving team care. Among team patients with a single 22q Center visit, a paired samples t test showed that mean adherence increased from 63% before the clinic encounter to 86% six months after the encounter (P < .001). Some guidelines were more likely to be associated with provider nonadherence, whereas others were more likely to be associated with patient nonadherence. CONCLUSIONS: Multidisciplinary team care is associated with significantly higher guideline adherence in children with 22q11DS. Additional research is needed to investigate the effect of team care on long-term health outcomes in children with 22q11DS.