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Introduction Residual dizziness (RD) is common in patients with benign paroxysmal positional vertigo (BPPV) after successful canalith repositioning procedures. This study aimed to investigate the therapeutic effects of vestibular rehabilitation (VR) on BPPV patients experiencing RD, and to explore the impact of VR on functional connectivity (FC), specifically focusing on the bilateral parietal operculum (OP) cortex. Methods Seventy patients with RD were randomly assigned to either a four-week VR group or a control group that received no treatment. Assessments included the dizziness Visual Analog Scale (VAS), Dizziness Handicap Inventory (DHI), Hamilton Anxiety/Depression Scale (HAMA/HAMD), and resting-state functional magnetic resonance imaging. Results The VR group exhibited a significant decline in scores on VAS, DHI, HAMA and HAMD following training (all p  < 0.05). Furthermore, the VR group demonstrated increased FC between the left OP and both the left precuneus and left middle frontal gyrus (MFG), and between the right OP and the right MFG (voxel-level p  < 0.001; cluster-level p  < 0.05, FDR corrected). Additionally, these changes in FC were found to correlate with clinical features, including scores on HAMA ( p  = 0.012, r =  − 0.513) and DHI ( p  = 0.022, r =  − 0.475) after the intervention. Conclusion This study demonstrated the therapeutic effects of VR in alleviating RD and emotional disorders, as well as in improving overall quality of life. Notably, these positive outcomes might be associated with increased FC between brain regions involved in mood regulation and vestibular processing. Our findings offer novel neuroimaging evidence that supports the hypothesis that VR facilitates dynamic vestibular compensation.

Purpose: Our objectives were to assess the quality of PET images and coregistered anatomic images obtained with PET/MR, to evaluate the detection of focal uptake and SUV, and to compare these findings with those of PET/CT in patients with head and neck tumours. Methods: The study group comprised 32 consecutive patients with malignant head and neck tumours who underwent whole-body super(18)F-FDG PET/MR and PET/CT. PET images were reconstructed using the attenuation correction sequence for PET/MR and CT for PET/CT. Two experienced observers evaluated the anonymized data. They evaluated image and fusion quality, lesion conspicuity, anatomic location, number and size of categorized (benign versus assumed malignant) lesions with focal uptake. Region of interest (ROI) analysis was performed to determine SUVs of lesions and organs for both modalities. Statistical analysis considered data clustering due to multiple lesions per patient. Results: PET/MR coregistration and image fusion was feasible in all patients. The analysis included 66 malignant lesions (tumours, metastatic lymph nodes and distant metastases), 136 benign lesions and 470 organ ROIs. There was no statistically significant difference between PET/MR and PET/CT regarding rating scores for image quality, fusion quality, lesion conspicuity or anatomic location, number of detected lesions and number of patients with and without malignant lesions. A high correlation was observed for SUV sub(mean) and SUV sub(max) measured on PET/MR and PET/CT for malignant lesions, benign lesions and organs (Ie=0.787 to 0.877, p<0.001). SUV sub(mean) and SUV sub(max) measured on PET/MR were significantly lower than on PET/CT for malignant tumours, metastatic neck nodes, benign lesions, bone marrow, and liver (p<0.05). The main factor affecting the difference between SUVs in malignant lesions was tumour size (p<0.01). Conclusion: In patients with head and neck tumours, PET/MR showed equivalent performance to PET/CT in terms of qualitative results. Comparison of SUVs revealed an excellent correlation for measurements on both modalities, but underestimation of SUVs measured on PET/MR as compared to PET/CT.

Background The evaluation and management of acute vertigo presentations is challenging for both patients and physicians. Benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (e.g., vestibular neuritis), and stroke are priority diagnostic considerations in this circumstance. Existing evidence can be used to guide the diagnosis and treatment, however high value care opportunities—such as the Dix-Hallpike test (DHT), canalith repositioning maneuver (CRM), and gaze stabilization exercises (GSE)—are often underused, while neuroimaging studies are often overused. Methods This trial contains a health system focused stepped wedge intervention and an embedded individually patient randomized clinical trial. The study will start with a 6-month pre-intervention period. This will be followed by staggered intervention at the engaged EDs in 11 waves and then an approximately 6-month post-intervention period. Concurrently, patients will be recruited before and after the physician level intervention is implemented at each ED. Enrolled participants will complete baseline survey and then be randomized individually, stratified by sex, age, and medical center, to the intervention or control arm patient materials using central computerized randomization. The intervention arm will be sent intervention materials and the control arm will be sent the hospital’s standard post-discharge materials. The primary outcome of the physician-based part of the trial is use of evidence-based care practices during the index ED visit. The primary outcome of the patient focused part of the trial is the dizziness handicap index over 4 weeks. Discussion The DIZZTINCT-2 trial addresses key areas of uncertainty in how to improve the care of emergency department patients with acute vertigo. In addition, follow up data on how much and how fast patients improved was needed. DIZZTINCT-2 will address these key knowledge gaps efficiently. Trial registration Clinicaltrials.gov NCT05634902. Registered on November 2022.

IntroductionEndobronchial Ultrasound (EBUS) allows minimally-invasive hilar and mediastinal lymph node sampling and has an established role in the diagnosis and staging of lung cancer. Molecular biomarker development is becoming increasingly relevant in lung cancer management, however the suitability of EBUS-derived aspirates for detailed molecular analysis is not fully defined. Gene expression profiling (GEP), a powerful micro-array technology, which assesses genome-wide changes in gene expression, can generate individual-specific molecular signatures that can provide prognostic information and predict treatment responsiveness. Here we demonstrate the feasibility of using EBUS-derived cytological aspirates from benign and tumour infiltrated lymph nodes in patients with NSCLC for GEP.MethodsCytological aspirates from six patients with known NSCLC that had been referred for EBUS to stage the mediastinum were selected for GEP. Three patient samples were infiltrated by NSCLC and three were benign. NSCLC-infiltrated and benign lymph nodes were compared for differences in gene expression.ResultsRNA was available at a yield (median 17.5 μg, range 0.7–62.3 μg) and integrity (RIN Median 7.1, range 5.3–8.0) suitable for amplification and GEP. Reactive and malignant nodes were differentiated by principal component analysis and hierarchical clustering with ability to identify upregulation of cancer specific genes in malignant relative to benign nodes (notably EGFR, HGFR/c-met and HER2 were among genes most upregulated).ConclusionWe demonstrate the feasibility of RNA extraction and GEP on EBUS-derived lymph node cytological aspirates and show differences in gene expression profiles between benign and tumour-infiltrated lymph node mRNA. Further studies on larger patient cohorts are necessary to identify expression profiles that can robustly differentiate benign from malignant lymph nodes in NSCLC.Abstract S57 Figure 1Scatter plot: Gene expression in malignant nodes (y axis) vs reactive nodes (x axis).

Background: Lesions of the breast that are classified BI-RADS super( registered )-US 3 by ultrasound are probably benign and observation is recommended, although malignancy may occasionally occur. In our study, we focus exclusively on BI-RADS super( registered )-US 3 lesions and hypothesize that sonoelastography as an adjunct to conventional ultrasound can identify a high-risk-group and a low-risk-group within these patients. Methods: A group of 177 breast lesions that were classified BI-RADS super( registered )-US 3 were additionally examined with real-time sonoelastography. Elastograms were evaluated according to the Tsukuba Elasticity Score. Pretest and posttest probability of disease (POD), sensitivity (SE), specificity (SP), positive (PPV) and negative predictive values (NPV) and likelihood-ratios (LR) were calculated. Furthermore, we analyzed the false-negative and false-positive cases and performed a model calculation to determine how elastography could affect the proceedings in population screening. Results: In our collection of BI-RADS super( registered )-US 3 cases there were 169 benign and eight malignant lesions. The pretest POD was 4.5% (95% confidence interval (CI): 2.1-9.0). In patients with a suspicious elastogram (high-risk group), the posttest POD was significantly higher (13.2%, p = 0.041) and the positive LR was 3.2 (95% CI: 1.7-5.9). With a benign elastogram (low-risk group), the posttest POD decreased to 2.2%. SE, SP, PPV and NPV for sonoelastography in BI-RADS super( registered )-US 3 lesions were 62.5% (95% CI: 25.9-89.8), 80.5% (95% CI: 73.5-86.0), 13.2% (95% CI: 5.0-28.9) and 97.8% (95% CI: 93.3-99.4), respectively. Conclusions: Sonoelastography yields additional diagnostic information in the evaluation of BI-RADS super( registered )-US 3 lesions of the breast. The examiner can identify a low-risk group that can be vigilantly observed and a high-risk group that should receive immediate biopsy due to an elevated breast cancer risk.

Purpose: This study aimed at demonstrating the feasibility of retrospectively fused super(18)F FDG-PET and MRI (PET/MRI fusion image) in diagnosing pancreatic tumor, in particular differentiating malignant tumor from benign lesions. In addition, we evaluated additional findings characterizing pancreatic lesions by FDG-PET/MRI fusion image. Methods: We analyzed retrospectively 119 patients: 96 cancers and 23 benign lesions. FDG-PET/MRI fusion images (PET/T1 WI or PET/T2WI) were made by dedicated software using 1.5 Tesla (T) MRI image and FDG-PET images. These images were interpreted by two well-trained radiologists without knowledge of clinical information and compared with FDG-PET/CT images. We compared the differential diagnostic capability between PET/CT and FDG-PET/MRI fusion image. In addition, we evaluated additional findings such as tumor structure and tumor invasion. Results: FDG-PET/MRI fusion image significantly improved accuracy compared with that of PET/CT (96.6 vs. 86.6 %). As additional finding, dilatation of main pancreatic duct was noted in 65.9 % of solid types and in 22.6 % of cystic types, on PET/MRI-T2 fusion image. Similarly, encasement of adjacent vessels was noted in 43.1 % of solid types and in 6.5 % of cystic types. Particularly in cystic types, intra-tumor structures such as mural nodule (35.4 %) or intra-cystic septum (74.2 %) were detected additionally. Besides, PET/MRI-T2 fusion image could detect extra benign cystic lesions (9.1 % in solid type and 9.7 % in cystic type) that were not noted by PET/CT. Conclusions: In diagnosing pancreatic lesions, FDG-PET/MRI fusion image was useful in differentiating pancreatic cancer from benign lesions. Furthermore, it was helpful in evaluating relationship between lesions and surrounding tissues as well as in detecting extra benign cysts.

Amblyopia is a developmental disorder of the central nervous system resulting in visual impairment, with potential impacts on cognitive and motor functions. This study evaluated the risk of benign paroxysmal positional vertigo (BPPV) in patients with amblyopia over a 9-year follow-up. Data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) was used. Amblyopia ( n  = 2,660) and non-amblyopia ( n  = 2,660) groups were matched by Propensity Score. The primary endpoint was the diagnosis of BPPV. Amblyopia was associated with a higher BPPV risk (HR 2.25, 95% CI: 1.49–3.41). The risk was lower in men (HR 0.47, 95% CI: 0.31–0.73) but increased with age (20–39 years: HR 3.35 [95% CI: 1.93–5.83]; 40–59 years: HR 9.92 [95% CI: 6.05–16.28]; ≥60 years: HR 14.80 [95% CI: 7.65–28.69]). In this long-term study, individuals with amblyopia had a 2.25-fold increased risk of developing BPPV compared to controls. These findings suggest that visual and vestibular functions are more closely linked than previously recognized, indicating that sensory disorders such as amblyopia may have broader neurological implications beyond vision alone. Nevertheless, the findings should be interpreted with caution and considered exploratory, providing population-level evidence for potential visual–vestibular associations that require validation in future prospective studies.

Balance disorders, unsteadiness, dizziness and vertigo in the elderly are a significant health problem, needing appropriate treatment. One third of elderly patients with vertigo were diagnosed with benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness in both primary care specialist Neurology and Ear Nose Throat settings. BPPV presents a specific paroxysmal positional nystagmus which can be obtained using the appropriate diagnostic positional test and can be treated effectively using specific therapeutic maneuvers. This review presents current insights into the diagnostic, pathogenetic and therapeutic aspects of BPPV in the elderly. BPPV in older patients does not differ significantly from BPPV in younger patients, with regard to pathogenesis, diagnosis and treatment. However, in older patients, its prevalence is higher and it responds less effectively to treatment, having a tendency for recurrence. Specific issues which should be considered in the elderly are: 1) difficulty in obtaining an accurate history; 2) difficulty in performing the diagnostic and therapeutic maneuvers, which should be executed with slow and gentle movements and extremely cautiously to avoid any vascular or orthopedic complications; and 3) the relation between BPPV and falls.

Background Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized. Methods/design This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts. Discussion If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts. Trial registration ClinicalTrials.gov, ID: NCT02809599 . The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Purpose To investigate the risk factors for residual dizziness (RD) in patients with benign paroxysmal positional vertigo (BPPV) after successful repositioning. Methods Searches were performed in PubMed, Embase, Cochrane library, Web of Science, Chinese National Knowledge Infrastructure, and Sino Med up to March 7, 2021 and references of relevant articles were screened. Data from eligible studies were meta-analyzed using Stata version 16.0 and Review Manager 5.4. Results In this systematic review and meta-analysis of 4487 patients from 31 studies, the prevalence of RD was 43.0% (95% CI 39.0–48.0%). Age (MD 4.17; 95% CI 2.13–6.21, P  = 0.000), female gender (OR = 1.28, 95% CI 1.11–1.47, P  = 0.001), secondary BPPV (OR 1.88; 95% CI 1.27–2.77, P  = 0.001), a longer duration of BPPV before treatment (MD 3.45; 95% CI 1.87–5.02, P  = 0.000), abnormal ocular vestibular evoked myogenic potential (OVEMP, OR 4.34; 95% CI 2.78–6.78, P  = 0.000), abnormal cervical vestibular evoked myogenic potential (CVEMP, OR 2.48; 95% CI 1.54–3.99, P  = 0.000), higher Dizziness Handicap Index (DHI) score before treatment (MD 10.88; 95% CI 5.96–15.80, P  = 0.000), anxiety (OR 9.58; 95% CI 6.32–14.52, P  = 0.000), osteopenia (OR = 4.40, 95% CI 2.17–8.96, P  = 0.000), onset in winter (OR 7.27; 95% CI 2.38–22.24, P  = 0.001) and with a history of BPPV (OR 1.79; 95% CI 1.06–3.04, P  = 0.03) are the risk factors for RD in patients with BPPV after successful repositioning. The affected side, location or type of semicircular involvement, hyperlipidemia, diabetes, hypertension, heart disease, migraine, sleep disorders, canalolithiasis/cupulolithiasis, the number of times the canalith repositioning procedures (CRPs) were performed and number of vertigo attacks did not correlate with the occurrence of RD. Conclusions Despite successful treatment, nearly half of the BPPV patients developed RD. RD seems to be a syndrome caused by multiple factors. The pathogenesis of most factors can be explained by psychological and/or physical disorders. Early recognition of these risk factors contributes to the prevention and treatment of RD.