Differentiating patients admitted primarily due to coronavirus disease 2019 (COVID-19) from those admitted with incidentally detected severe acute respiratory syndrome corona-virus type 2 (SARS-CoV-2) at hospital admission: A cohort analysis of German hospital records.

OBJECTIVE: The number of hospitalized patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) does not differentiate between patients admitted due to coronavirus disease 2019 (COVID-19) (ie, primary cases) and incidental SARS-CoV-2 infection (ie, incidental cases). We developed an adaptable method to distinguish primary cases from incidental cases upon hospital admission. DESIGN: Retrospective cohort study. SETTING: Data were obtained from 3 German tertiary-care hospitals. PATIENTS: The study included patients of all ages who tested positive for SARS-CoV-2 by a standard quantitative reverse-transcription polymerase chain reaction (RT-PCR) assay upon admission between January and June 2022. METHODS: We present 2 distinct models: (1) a point-of-care model that can be used shortly after admission based on a limited range of parameters and (2) a more extended point-of-care model based on parameters that are available within the first 24-48 hours after admission. We used regression and tree-based classification models with internal and external validation. RESULTS: In total, 1,150 patients were included (mean age, 49.5±28.5 years; 46% female; 40% primary cases). Both point-of-care models showed good discrimination with area under the curve (AUC) values of 0.80 and 0.87, respectively. As main predictors, we used admission diagnosis codes (ICD-10-GM), ward of admission, and for the extended model, we included viral load, need for oxygen, leucocyte count, and C-reactive protein. CONCLUSIONS: We propose 2 predictive algorithms based on routine clinical data that differentiate primary COVID-19 from incidental SARS-CoV-2 infection. These algorithms can provide a precise surveillance tool that can contribute to pandemic preparedness. They can easily be modified to be used in future pandemic, epidemic, and endemic situations all over the world.

Symptoms in unilateral vestibular hypofunction are associated with number of catch-up saccades and retinal error: results from the population-based KORA FF4 study.

Objective: The presence and intensity of symptoms vary in patients with unilateral vestibular hypofunction. We aimed to determine which saccadic and vestibulo-ocular reflex parameters best predict the presence of symptoms in unilateral vestibular hypofunction in order to better understand vestibular compensation and its implications for rehabilitation therapy. Methods: Video head impulse test data were analyzed from a subpopulation of 23 symptomatic and 10 currently symptom-free participants with unilateral vestibular hypofunction, embedded in the KORA (Cooperative Health Research in the Region of Augsburg) FF4 study, the second follow-up of the KORA S4 population-based health survey (2,279 participants). Results: A higher number of catch-up saccades, a higher percentage of covert saccades, and a larger retinal error at 200 ms after the onset of the head impulse were associated with relevant symptoms in participants with unilateral vestibular hypofunction (p = 0.028, p = 0.046, and p = 0.038, respectively). After stepwise selection, the number of catch-up saccades and retinal error at 200 ms remained in the final logistic regression model, which was significantly better than a null model (p = 0.014). Age, gender, saccade amplitude, saccade latency, and VOR gain were not predictive of the presence of symptoms. Conclusion: The accuracy of saccadic compensation seems to be crucial for the presence of symptoms in unilateral vestibular hypofunction, highlighting the role of specific gaze stabilization exercises in rehabilitation. Early saccades, mainly triggered by the vestibular system, do not seem to compensate accurately enough, resulting in a relevant retinal error and the need for more as well as more accurate catch-up saccades, probably triggered by the visual system.

Anxiety and physical impairment in patients with central vestibular disorders.

BACKGROUND: There is increasing evidence for close interrelations between vestibular and emotional brain networks. A study in patients with bilateral peripheral vestibulopathy (BVP) showed relatively low vertigo-related anxiety (VRA), despite high physical impairment. The current working hypothesis proposes the integrity of the peripheral vestibular system as a prerequisite for development of VRA. Here we contribute by evaluating VRA and vestibular-related handicap in central vestibular disorders. METHODS: Of 6396 patients presenting in a tertiary vertigo centre, 306 were identified with four clear central vestibular disorders: pure cerebellar ocular motor disorder (COD; 61), cerebellar ataxia (CA; 63), atypical parkinsonian syndromes (APS; 28), vestibular migraine (VM; 154). Their results of the Vertigo Handicap Questionnaire (VHQ), with its subscales for anxiety and handicapped activity, were compared to those of 65 BVP patients. Postural instability was measured on a force-plate. Multivariate linear regression was used to adjust for patient demographics. RESULTS: Patients with chronic central vestibular disorders (COD, CA, APS) had relatively low VRA levels comparable to those in BVP, independent of increased handicapped activity or postural instability. Only VM patients showed significantly higher VRA, although their activity impairment and postural instability were lowest. No significant differences within chronic central vestibular disorders were found for VRA and subjective activity impairment. CONCLUSIONS: Subjective and objective vestibular-related impairment are not necessarily correlated with vestibular-related anxiety in central vestibular disorders. Our findings rather support the hypothesis that, in addition to an intact peripheral, an intact central vestibular system could also serve as a prerequisite to develop specific VRA.

Persistent symptoms and risk factors predicting prolonged time to symptom-free after SARS­CoV­2 infection: an analysis of the baseline examination of the German COVIDOM/NAPKON-POP cohort.

PURPOSE: We aimed to assess symptoms in patients after SARS-CoV-2 infection and to identify factors predicting prolonged time to symptom-free. METHODS: COVIDOM/NAPKON-POP is a population-based prospective cohort of adults whose first on-site visits were scheduled ≥ 6 months after a positive SARS-CoV-2 PCR test. Retrospective data including self-reported symptoms and time to symptom-free were collected during the survey before a site visit. In the survival analyses, being symptom-free served as the event and time to be symptom-free as the time variable. Data were visualized with Kaplan-Meier curves, differences were tested with log-rank tests. A stratified Cox proportional hazard model was used to estimate adjusted hazard ratios (aHRs) of predictors, with aHR < 1 indicating a longer time to symptom-free. RESULTS: Of 1175 symptomatic participants included in the present analysis, 636 (54.1%) reported persistent symptoms after 280 days (SD 68) post infection. 25% of participants were free from symptoms after 18 days [quartiles: 14, 21]. Factors associated with prolonged time to symptom-free were age 49-59 years compared to < 49 years (aHR 0.70, 95% CI 0.56-0.87), female sex (aHR 0.78, 95% CI 0.65-0.93), lower educational level (aHR 0.77, 95% CI 0.64-0.93), living with a partner (aHR 0.81, 95% CI 0.66-0.99), low resilience (aHR 0.65, 95% CI 0.47-0.90), steroid treatment (aHR 0.22, 95% CI 0.05-0.90) and no medication (aHR 0.74, 95% CI 0.62-0.89) during acute infection. CONCLUSION: In the studied population, COVID-19 symptoms had resolved in one-quarter of participants within 18 days, and in 34.5% within 28 days. Over half of the participants reported COVID-19-related symptoms 9 months after infection. Symptom persistence was predominantly determined by participant's characteristics that are difficult to modify.

Exposure to anticholinergic and sedative medication is associated with impaired functioning in older people with vertigo, dizziness and balance disorders-Results from the longitudinal multicenter study MobilE-TRA.

Introduction: Anticholinergic and sedative medication is prescribed for various conditions in older patients. While the general association between anticholinergic and sedative medication and impaired functioning is well established, its specific role in older individuals with vertigo, dizziness, and balance disorders (VDB) is still incompletely understood. The objective of this study was to investigate, whether an exposure to anticholinergic and sedative medication is associated with lower generic and lower vertigo-specific functioning in older patients with VDB. Methods: Data originates from the longitudinal multicenter study MobilE-TRA with two follow-ups, conducted from 2017 to 2019 in two German federal states. Exposure to anticholinergic and sedative medication was quantified using the drug burden index (DBI). Generic functioning was assessed by the Health Assessment Questionnaire Disability Index, appraising the amount of difficulties in performing activities of daily living (ADL). Vertigo-specific functioning was measured using the Vestibular Activities and Participation (VAP) questionnaire, assessing patient-reported functioning regarding activities of daily living that are difficult to perform because of their propensity to provoke VDB (Scale 1) as well as immediate consequences of VDB on activities and participation related to mobility (Scale 2). Longitudinal linear mixed models were applied to assess the association of exposure to anticholinergic and sedative medication at baseline and the level of generic and vertigo-specific functioning status over time. Results: An overall of 19 (7 from Bavaria) primary care physicians (mean age = 54 years, 29% female) recruited 158 (59% from Bavaria) patients with VDB (median age = 78 years, 70% female). Anticholinergic and sedative medication at baseline was present in 56 (35%) patients. An exposure to anticholinergic and sedative medication at baseline was significantly associated with lower generic functioning [Beta = 0.40, 95%-CI (0.18; 0.61)] and lower vertigo-specific functioning [VAP Scale 1: Beta = 2.47, 95%-CI (0.92; 4.02)], and VAP Scale 2: Beta = 3.74, 95%-CI [2.23; 5.24]). Conclusion: Our results highlight the importance of a close monitoring of anticholinergic and sedative medication use in older patients with VDB. When feasible, anticholinergic and sedative medication should be replaced by equivalent alternative therapies in order to potentially reduce the burden of VDB.

Impact of episodic and chronic vestibular disorders on health-related quality of life and functioning-results from the DizzyReg patient registry.

PURPOSE: Vertigo and dizziness belong to the most frequent syndromes in the primary, secondary and tertiary setting and can be divided into vertigo with episodic or chronic persistent complaints. Episodic vertigo (EVS) is characterized by recurrent attacks of vertigo or dizziness with intermittent symptom-free periods, while chronic vertigo (CVS) presents with persistent vertigo. It is still not completely understood how EVS or CVS affect health-related quality of life (HRQoL) and functioning. METHODS: Data originates from the DizzyReg patient registry, an ongoing prospective clinical patient registry situated at tertiary clinic at the university hospital, Munich. HRQoL and functioning was measured by self-report. CVS and EVS was categorized after comprehensive neuro-otological work-up in line with the diagnostic guidelines. Association of CVS and EVS was assessed with multivariable linear regression models adjusting for potential risk factors and confounders. RESULTS: The study included 548 patients (57% female, mean age 51.35). Patients with EVS were significantly younger (48.5 vs. 59.6 years) and were more often female (60 vs. 49%). EVS patients reported significantly better functioning (42.1 vs. 47.8) and HRQoL (63.87 vs. 58.08) than CVS patients. The effect was stable after adjusting for potential confounders. CONCLUSION: This is the first study to show worse HRQoL in patients with CVS compared to EVS. The results of the study underpin the experience from clinical practice that mobility and balance control are especially important for patients with CVS.

Association of self-efficacy, risk attitudes, and time preferences with functioning in older patients with vertigo, dizziness, and balance disorders in a tertiary care setting-Results from the MobilE-TRA2 cohort.

Introduction: The functional burden of vertigo, dizziness, and balance problems (VDB) might depend on the personality traits of the patients affected. The aim of this study thus was to investigate the impact of self-efficacy, risk attitudes, and time preferences on functioning in older patients with VDB before and after treatment in a specialized tertiary care center. Methods: Data for this study was obtained from the MobilE-TRA2 cohort study, conducted at a specialized tertiary care center in Germany. Patients aged 60 and older were assessed during their initial stay at the care center and 3 months later, using self-administered questionnaires. Self-efficacy was measured on a scale from 1 (very low) to 5 (very high). Health-related risk attitudes were inquired using an 11-point scale. Time preferences were measured by evaluating patients' willingness to postpone a reward in favor of a greater benefit on an 11-point Likert scale. Functioning was evaluated using the Dizziness Handicap Inventory, representing functional, emotional, and physical aspects of functional disability caused by VDB. Mixed-effects regression models were used to analyze the association between the selected personality traits and functioning over time. Interaction terms with time were incorporated for each personality trait, enabling the assessment of their influence on functioning 3 months following the initial observation period. Results: An overall of 337 patients (53% women, median age at baseline = 70 years) were included. Patients with higher self-efficacy (Beta = -3.82, 95%-CI [-6.56; -1.08]) and higher willingness to take risks (Beta = -1.31, 95%-CI [-2.31; -0.31]) reported better functioning during their initial visit at the care center. Self-efficacy significantly predicted functioning after 3 months for overall functioning (Beta = -4.21, 95%-CI [-6.57; -1.84]) and all three domains. Conclusion: Our findings suggest that patients with high self-efficacy and high willingness to take risks may exhibit better coping mechanisms when faced with the challenges of VDB. Promoting self-efficacy may help patients to better manage the duties accompanying their treatment, leading to improved functioning. These insights may inform the development of personalized treatment aimed at reducing the functional burden of VDB in older patients.

Episodic ataxias in children and adolescents: Clinical findings and suggested diagnostic criteria.

Background: The main clinical presentation of episodic ataxias (EAs) consists of vertigo and dizziness attacks lasting for minutes to hours with widely varying accompanying symptoms. The differentiation of EA and episodic vertigo/dizziness syndromes in childhood and adolescence such as vestibular migraine (VM) and recurrent vertigo of childhood (RVC) can be challenging. Furthermore, only few prospective studies of children/adolescents with EA are available. Objective: This study aims to characterize clinical and instrument-based findings in EA patients under 18 years of age, to delineate the clinical and therapeutic course in EA, and to present potentially new genetic mutations. Furthermore, the study aims to differentiate distinct characteristics between EA, VM, and RVC patients. Methods: We prospectively collected clinical and instrument-based data of patients younger than 18 years, who presented at the German Center for Vertigo and Balance Disorders (DSGZ) at the LMU University Hospital in Munich with EA, VM, or RVC between January 2016 and December 2021. All patients underwent a comprehensive evaluation of neurological, ocular-motor, vestibular and cochlear function, including video-oculography with caloric testing, video head impulse test, vestibular evoked myogenic potentials, posturography, and gait analysis. Results: Ten patients with EA, 15 with VM, and 15 with RVC were included. In EA the main symptoms were vertigo/dizziness attacks lasting between 5 min and 12 h. Common accompanying symptoms included walking difficulties, paleness, and speech difficulties. Six EA patients had a previously unknown gene mutation. In the interictal interval all EA patients showed distinct ocular-motor deficits. Significant differences between EA, VM, and RVC were found for accompanying symptoms such as speech disturbances and paleness, and for the trigger factor "physical activity". Furthermore, in the interictal interval significant group differences were observed for different pathological nystagmus types, a saccadic smooth pursuit, and disturbed fixation suppression. Conclusion: By combining clinical and ocular-motor characteristics we propose diagnostic criteria that can help to diagnose EA among children/adolescents and identify patients with EA even without distinct genetic findings. Nevertheless, broad genetic testing (e.g., next generation sequencing) in patients fulfilling the diagnostic criteria should be conducted to identify even rare or unknown genetic mutations for EA.

Determinants of functioning and health-related quality of life after vestibular stroke.

Background: Stroke accounts for 5-10% of all presentations with acute vertigo and dizziness. The objective of the current study was to examine determinants of long-term functioning and health-related quality of life (HRQoL) in a patient cohort with vestibular stroke. Methods: Thirty-six patients (mean age: 66.1 years, 39% female) with an MRI-proven vestibular stroke were followed prospectively (mean time: 30.2 months) in the context of the EMVERT (EMergency VERTigo) cohort study at the Ludwig-Maximilians Universität, Munich. The following scores were obtained once in the acute stage (<24 h of symptom onset) and once during long-term follow-up (preferably >1 year after stroke): European Quality of Life Scale-five dimensions-five levels questionnaire (EQ-5D-5L) and Visual Analog Scale (EQ-VAS) for HRQoL, Dizziness Handicap Inventory (DHI) for symptom severity, and modified Rankin Scale (mRS) for general functioning and disability. Anxiety state and trait were evaluated by STAI-S/STAI-T, and depression was evaluated by the Patient Health Questionnaire-9 (PHQ-9). Voxel-based lesion mapping was applied in normalized MRIs to analyze stroke volume and localization. Multiple linear regression models were calculated to determine predictors of functional outcome (DHI, EQ-VAS at follow-up). Results: Mean DHI scores improved significantly from 45.0 in the acute stage to 18.1 at follow-up (p < 0.001), and mean mRS improved from 2.1 to 1.1 (p < 0.001). Mean HRQoL (EQ-5D-5L index/EQ-VAS) changed from 0.69/58.8 to 0.83/65.2 (p = 0.01/p = 0.11). Multiple linear regression models identified higher scores of STAI-T and DHI at the time of acute vestibular stroke and larger stroke volume as significant predictors for higher DHI at follow-up assessment. The effect of STAI-T was additionally enhanced in women. There was a significant effect of patient age on EQ-VAS, but not DHI during follow-up. Conclusion: The average functional outcome of strokes with the chief complaint of vertigo and dizziness is favorable. The most relevant predictors for individual outcomes are the personal anxiety trait (especially in combination with the female sex), the initial symptom intensity, and lesion volume. These factors should be considered for therapeutic decisions both in the acute stage of stroke and during subsequent rehabilitation.

Longitudinal changes of mental health problems in children and adolescents treated in a primary care-based health-coaching programme - results of the PrimA-QuO cohort study.

BACKGROUND: In Germany, 19.1% of boys and 14.5% of girls are affected by mental health problems (MHP). Paediatricians are usually the first in line to be contacted but they often do not feel adequately trained to diagnose and treat MHP in primary care. A major statutory health insurance fund introduced a health coaching (HC) programme to strengthen primary care consultation for MHP. The HC includes a training concept for paediatricians, standardised guidelines for actions and additional payments. The aim of this study was to investigate the potential effects of the HC programme on the change of MHP in children and adolescents. METHODS: A prospective cohort study was conducted in Bavaria, Germany, in 2018 and 2019. Data were collected at 2 points 1 year apart using an online questionnaire. Parents of patients with developmental disorder of speech and language, head/abdominal pain, conduct disorder or non-organic enuresis were approached by their health insurance. Families treated according to the HC programme form the intervention group while all others serve as controls. MHP was assessed using the Strengths and Difficulties Questionnaire (SDQ) as a child self-assessment (SDQ-S)/or external assessment by parents (SDQ-P). Determinants of SDQ total score were analysed using linear mixed effects models. RESULTS: Cross-sectional (n = 1090) and longitudinal analyses (n = 599) were performed. At baseline, a total of 23.5% had an SDQ total score "at risk" (SDQ-S > 15/SDQ-P > 13). There were no significant differences between intervention and controls. After full adjustment for all potential confounders, higher SDQ scores indicating more problems were significantly associated with male sex (2.000, p < 0.001) whereas a high parental education level was significantly associated with decreased SDQ scores (-2.127, p =0.034). There was a significant improvement in the control group over time (-0.814, p = 0.001) while the SDQ scores in the intervention group remained stable (-0.012, p = 0.020). CONCLUSION: This evaluation of the HC programme could not prove a clinically relevant intervention's effect on the MHP developmental course. Nevertheless, (HC) paediatricians have crucial potential to improve the care of MHP patients. Targeting families with less access to support measures might help reduce the burden of MHP and be a step towards continuous improvement of care.

Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness.

BACKGROUND AND PURPOSE: Vertigo and dizziness are common complaints in emergency departments and primary care, and pose major diagnostic challenges due to their various underlying etiologies. Most supportive diagnostic algorithms concentrate on either identifying cerebrovascular events (CVEs) or diagnosing specific vestibular disorders or are restricted to specific patient subgroups. The aim of the present study was to develop and validate a comprehenisve algorithm for identifying patients with CVE and classifying the most common vestibular disorders. METHODS: The study was conducted within the scope of the "PoiSe" project (Prevention, Online feedback, and Interdisciplinary Therapy of Acute Vestibular Syndromes by e-health). A three-level algorithm was developed according to international guidelines and scientific evidence, addressing both the detection of CVEs and the classification of non-vascular vestibular disorders (unilateral vestibulopathy, benign paroxysmal positional vertigo, vestibular paroxysmia, Menière's disease, vestibular migraine, functional dizziness). The algorithm was validated in a prospectively collected dataset of 407 patients with acute vertigo and dizziness presenting to the Emergency Department at the Ludwig-Maximilian University of Munich. RESULTS: The algorithm assigned 287 of 407 patients to the correct diagnosis, corresponding to an overall accuracy of 71%. CVEs were identified with high sensitivity of 94%. The six most common vestibular disorders were classified with high specificity, above 95%. Random forest identified presence of a paresis, sensory loss, central ocular motor and vestibular signs (HINTS [head impulse test, nystagmus assessment, and test of skew deviation]), and older age as the most important variables indicating a cerebrovascular event. CONCLUSIONS: The proposed diagnostic algorithm can correctly classify the most common vestibular disorders based on a comprehensive set of key questions and clinical examinations. It is easily applied, not limited to subgroups, and might therefore be transferred to broad clinical settings such as primary healthcare.

Vestibular paroxysmia: clinical characteristics and long-term course.

In 2016, the Bárány Society defined new diagnostic criteria for the neurovascular compression syndrome of the eighth nerve, called "vestibular paroxysmia" (VP), differentiating between definite (dVP) and probable (pVP) forms. The aim of this study was (1) to describe clinical symptoms and laboratory findings in a well-diagnosed large patient cohort according to those criteria, and (2) to evaluate the long-term course over years in dVP. We identified 146 patients (73 dVP, 73 pVP) from our tertiary dizziness center registry. Data of structured history-taking, clinical neurological, neuro-ophthalmological/-otological examinations as well as MRI imaging were extracted for analyses. Overall, attack frequency ranged between 5 and 30 attacks per day; spinning vertigo was the most frequent type. In two-thirds of patients, attacks occurred spontaneously; in one-quarter, they were triggered by head movements. The majority (approximately 70%) reported no accompanying symptoms; in those with symptoms, mild unilateral cochlear symptoms prevailed. One-third of patients initially showed hyperventilation-induced nystagmus without specific direction, and a deviation of the subjective visual vertical between 3° and 6°. Complete loss of peripheral vestibular function was never evident. dVP and pVP significantly differed concerning the vertigo type, e.g., spinning vertigo was more frequent in dVP. Fortunately, three-quarters of dVP patients remained attack-free during follow-up (mean 4.8 years, standardized questionnaire), more than half of them even without any medication. Patients with ongoing attacks showed significantly higher attack frequency at baseline, but reported persistent frequency reduction. Overall, the long-term prognosis of VP appears favorable, not necessarily requiring ongoing treatment.

Referral trajectories in patients with vertigo, dizziness and balance disorders and their impact on health-related quality of life and functioning: results from the longitudinal multicenter study MobilE-TRA.

BACKGROUND: Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients' functioning and health-related quality of life (HRQoL). METHODS: Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients' HRQoL and functioning. RESULTS: We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning. CONCLUSION: Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients' HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning.

Chronic vestibular syndromes in the elderly: Presbyvestibulopathy-an isolated clinical entity?

BACKGROUND AND PURPOSE: Recently, the Classification Committee of the Bárány Society defined the new syndrome of "presbyvestibulopathy" for elderly patients with chronic vestibular symptoms due to a mild bilateral peripheral vestibular hypofunction. However, control of stance and gait requires multiple functioning systems, for example, the somatosensory, visual, auditory, musculoskeletal, and cardio- and cerebrovascular systems. The aim of this cross-sectional database-driven study was to evaluate the frequency and characteristics of presbyvestibulopathy and additional gait-relevant comorbidities. METHODS: In total, 707 patients aged ≥60 years with chronic vertigo/dizziness were admitted to our tertiary hospital and received detailed neurological, neuro-orthoptic, and laboratory audiovestibular examination. Medical history, comorbidities, functional impairment, and quality of life (Dizziness Handicap Inventory [DHI], European Quality of Life Scale, Vestibular Activities and Participation) were compared between presbyvestibulopathy and bilateral vestibulopathy in a matched-paired study. RESULTS: In 95.5% of patients, complaints were better accounted for by another vestibular, neurological, cardiac, or psychiatric disease, and 32 patients (4.5%) met the diagnostic criteria for presbyvestibulopathy. Of these 32 patients, the majority showed further relevant comorbidities in other sensorimotor systems. Only one patient of 707 had "isolated" presbyvestibulopathy (0.14%). The mean total DHI scores indicated lower moderate impairment in presbyvestibulopathy than in bilateral vestibulopathy (40.6 vs. 49.0), which was confirmed by significant differences in the matched-paired analysis (p < 0.001). CONCLUSIONS: Isolated presbyvestibulopathy is a very rare entity. It is regularly accompanied by other multisensory dysfunctions. These results indicate a potential role of mild vestibular hypofunction as a cofactor in multifactorial impairment. Thus, patients should be treated in an interdisciplinary setting with an awareness of diverse comorbidities.

Diagnosis of Menière's disease according to the criteria of 2015: Characteristics and challenges in 96 patients.

BACKGROUND: The diagnosis of Menière's disease (MD) is made according to diagnostic criteria, the last revision of which was in 2015. For diagnosis, symptoms are weighted with audiometric findings and this can be challenging in individual patients. OBJECTIVE: To analyze patient's characteristics and symptoms in a real-life cohort of 96 patients with diagnosed MD regarding sociodemographic parameters, clinical specifics, and audiometry. METHODS: Prospective clinical patient registry containing demographic and socioeconomic parameters, symptoms, as well as pure-tone audiometry data. RESULTS: 31 patients with definite MD, and 36 with probable MD were identified. 29 patients showed typical clinical signs of MD, but did not meet the full diagnostic criteria, and were considered separately. Mean duration of symptoms prior to presentation was 3.9±4.6 years. Significant differences between categories were found regarding aural fullness, tinnitus, and fluctuating hearing. If multiple audiograms were available, 28.6 % (6/21) documented fluctuating hearing. CONCLUSIONS: Current diagnostic criteria probably do not represent patients with monosymptomatic presentation or an early stage very well. Long-term follow-up with repeated audiometry is advisable.

Effect of food insecurity on mental health of patients with tuberculosis in Southwest Ethiopia: a prospective cohort study.

OBJECTIVE: The objective of this study is to investigate the effect of food insecurity on the mental health of patients with tuberculosis (TB) in Ethiopia. DESIGN: A prospective cohort study. SETTING: Health centres and hospitals located in Jimma zone, Southwest Ethiopia. PARTICIPANTS: Patients with TB who had recently been diagnosed with TB and started directly observed treatment in the selected 26 health institutions from October 2017 to October 2018. A total of 268 patients were followed for 6 months and data were collected at recruitment and two follow-up visits (at 2 and 6 months). Patients with multidrug-resistant TB were not included in the study. MAIN OUTCOME MEASURES: Mental distress was measured by the Self-Reporting Questionnaire-20 while food insecurity was assessed by using the Household Food Insecurity Access Scale. RESULTS: A total of 268 patients were recruited and there was no lost to follow-up. The prevalence of food insecurity at baseline, first and second follow-up was 49.3%, 45.9% and 39.6%, respectively. Of these, 28.0% of them reported severe food insecurity at baseline which declined to 23.5% at the end of the sixth month. Likewise, the prevalence of mental distress at baseline was 61.2% but declined to 22.0% at the second follow-up. At baseline, 77.3% of patients with mental distress reported severe food insecurity but declined to 46.0% at second follow-up. In the final model, severe food insecurity (OR 4.7, 95% CI 2.4 to 9.4) and being a government employee (adjusted odds ratio (aOR) 0.3, 95% CI 0.1 to 0.9) were associated with mental distress. CONCLUSION: In this study, food insecurity was associated with mental distress over the course of follow-up. Likewise, there is a high prevalence of food insecurity and mental distress among patients with TB on treatment. Therefore, early assessment and interventions for food insecurity may improve the mental health of patients with TB on treatment.

Using Base-ml to Learn Classification of Common Vestibular Disorders on DizzyReg Registry Data.

Background: Multivariable analyses (MVA) and machine learning (ML) applied on large datasets may have a high potential to provide clinical decision support in neuro-otology and reveal further avenues for vestibular research. To this end, we build base-ml, a comprehensive MVA/ML software tool, and applied it to three increasingly difficult clinical objectives in differentiation of common vestibular disorders, using data from a large prospective clinical patient registry (DizzyReg). Methods: Base-ml features a full MVA/ML pipeline for classification of multimodal patient data, comprising tools for data loading and pre-processing; a stringent scheme for nested and stratified cross-validation including hyper-parameter optimization; a set of 11 classifiers, ranging from commonly used algorithms like logistic regression and random forests, to artificial neural network models, including a graph-based deep learning model which we recently proposed; a multi-faceted evaluation of classification metrics; tools from the domain of "Explainable AI" that illustrate the input distribution and a statistical analysis of the most important features identified by multiple classifiers. Results: In the first clinical task, classification of the bilateral vestibular failure (N = 66) vs. functional dizziness (N = 346) was possible with a classification accuracy ranging up to 92.5% (Random Forest). In the second task, primary functional dizziness (N = 151) vs. secondary functional dizziness (following an organic vestibular syndrome) (N = 204), was classifiable with an accuracy ranging from 56.5 to 64.2% (k-nearest neighbors/logistic regression). The third task compared four episodic disorders, benign paroxysmal positional vertigo (N = 134), vestibular paroxysmia (N = 49), Menière disease (N = 142) and vestibular migraine (N = 215). Classification accuracy ranged between 25.9 and 50.4% (Naïve Bayes/Support Vector Machine). Recent (graph-) deep learning models classified well in all three tasks, but not significantly better than more traditional ML methods. Classifiers reliably identified clinically relevant features as most important toward classification. Conclusion: The three clinical tasks yielded classification results that correlate with the clinical intuition regarding the difficulty of diagnosis. It is favorable to apply an array of MVA/ML algorithms rather than a single one, to avoid under-estimation of classification accuracy. Base-ml provides a systematic benchmarking of classifiers, with a standardized output of MVA/ML performance on clinical tasks. To alleviate re-implementation efforts, we provide base-ml as an open-source tool for the community.

Substance use disorders and adherence to antituberculosis medications in Southwest Ethiopia: a prospective cohort study.

OBJECTIVES: In Ethiopia, little is known about the association between substance use disorders and adherence to antituberculosis (anti-TB) medications. Therefore, the objective of this study was to assess the effect of substance use disorders on adherence to anti-TB medications in Southwest Ethiopia. DESIGN: Prospective cohort study. SETTINGS: Patients were recruited from 22 health centres and four hospitals in Southwest Ethiopia. PARTICIPANTS: This study was conducted among 268 patients with TB, aged 18-80 in Southwest Ethiopia between October 2017 and October 2018. At baseline, patients who were exposed substance use disorders (134 patients) and unexposed to substance use disorders (134 patients) were recruited. Patients were followed for 6 months, and data were collected on three occasions. MAIN OUTCOME MEASURE: Adherence to anti-TB medications. RESULTS: Patients with substance use disorders had consistently higher prevalence of non-adherence than those without, 16.4% versus 3.0% at baseline, 41.7% versus 14.4% at 2-month follow-up and 45.7% versus 10.8% at 6-month follow-up assessments. Patients with khat use disorder were 3.8 times more likely to be non-adherent to anti-TB medications than patients without khat use disorder (Adjusted odds ratio (aOR)=3.8, 95% CI 1.8 to 8.0). Patients who had alcohol use disorder (AUD) were also 3.2 times likely to have poor adherence compared with their counterparts (aOR=3.2, 95% CI 1.6 to 6.6). In addition, being educated (aOR=4.4, 95% CI 1.7 to 11.3), and being merchant (aOR=6.1, 95% CI 1.2 to 30.8) were associated with non-adherence to anti-TB medications. CONCLUSION: Khat and AUDs predict greater likelihood of non-adherence to anti-TB medication. This implies the need to integrate the management for substance use disorders into the existing TB treatment services.

A Set of Eight Key Questions Helps to Classify Common Vestibular Disorders-Results From the DizzyReg Patient Registry.

Precise history taking is the key to develop a first assumption on the diagnosis of vestibular disorders. Particularly in the primary care setting, algorithms are needed, which are based on a small number of questions and variables only to guide appropriate diagnostic decisions. The aim of this study is to identify a set of such key variables that can be used for preliminary classification of the most common vestibular disorders. A four-step approach was implemented to achieve this aim: (1) we conducted an online expert survey to collect variables that are meaningful for medical history taking, (2) we used qualitative content analysis to structure these variables, (3) we identified matching variables of the patient registry of the German Center for Vertigo and Balance Disorders, and (4) we used classification trees to build a classification model based on these identified variables and to analyze if and how these variables contribute to the classification of common vestibular disorders. We included a total of 1,066 patients with seven common vestibular disorders (mean age of 51.1 years, SD = 15.3, 56% female). Functional dizziness was the most frequent diagnosis (32.5%), followed by vestibular migraine (20.2%) and Menière's disease (13.3%). Using classification trees, we identified eight key variables which can differentiate the seven vestibular disorders with an accuracy of almost 50%. The key questions comprised attack duration, rotational vertigo, hearing problems, turning in bed as a trigger, doing sport or heavy household chores as a trigger, age, having problems with walking in the dark, and vomiting. The presented algorithm showed a high-face validity and can be helpful for taking initial medical history in patients with vertigo and dizziness. Further research is required to evaluate if the identified algorithm can be applied in the primary care setting and to evaluate its external validity.

Correction to: Development and validation of a classification algorithm to diagnose and differentiate spontaneous episodic vertigo syndromes: results from the DizzyReg patient registry.

The original version of this article unfortunately contained a mistake. The given names and family names were interchanged.