Remote Delivery of Vestibular Rehabilitation for Vestibular Dysfunction: A Systematic Review.

BACKGROUND: People with vestibular dysfunction encounter many obstacles when seeking vestibular rehabilitation treatment. Remote delivery of vestibular rehabilitation may offer a promising avenue for overcoming these barriers, ensuring uninterrupted and cost-effective care. OBJECTIVE: To evaluate clinical trials studying telerehabilitation and virtual reality devices as therapeutic interventions for individuals with vestibular dysfunction. METHODS: A PRISMA systematic review of PubMed, EMBASE, Cochrane, Web of Science, and SCOPUS was conducted for randomized controlled trials describing the use of remote care delivery for vestibular rehabilitation. Bias of studies was assessed with the revised Cochrane risk-of-bias tool (RoB2). RESULTS: The search identified 1,358 unique articles and 14 articles matched the search criteria. Study samples size ranged from 20 to 337, with mean ages ranging from 29.3 to 77.7 years. Interventions included telephone and online communication, exergaming devices, web-based applications, and head-mounted devices to deliver vestibular rehabilitation. Outcomes included validated questionnaires, objective clinical tests, and physical examinations. CONCLUSIONS: The studies reviewed in this article reported greater or equivalent outcomes when incorporating remote care options as supplements or alternatives to standard care for patients with vestibular dysfunction. Further research is required to address limitations in these studies such as heterogeneity of control groups and cost-effectiveness of these interventions.

ChatGPT vs. web search for patient questions: what does ChatGPT do better?

PURPOSE: Chat generative pretrained transformer (ChatGPT) has the potential to significantly impact how patients acquire medical information online. Here, we characterize the readability and appropriateness of ChatGPT responses to a range of patient questions compared to results from traditional web searches. METHODS: Patient questions related to the published Clinical Practice Guidelines by the American Academy of Otolaryngology-Head and Neck Surgery were sourced from existing online posts. Questions were categorized using a modified Rothwell classification system into (1) fact, (2) policy, and (3) diagnosis and recommendations. These were queried using ChatGPT and traditional web search. All results were evaluated on readability (Flesch Reading Ease and Flesch-Kinkaid Grade Level) and understandability (Patient Education Materials Assessment Tool). Accuracy was assessed by two blinded clinical evaluators using a three-point ordinal scale. RESULTS: 54 questions were organized into fact (37.0%), policy (37.0%), and diagnosis (25.8%). The average readability for ChatGPT responses was lower than traditional web search (FRE: 42.3 ± 13.1 vs. 55.6 ± 10.5, p < 0.001), while the PEMAT understandability was equivalent (93.8% vs. 93.5%, p = 0.17). ChatGPT scored higher than web search for questions the 'Diagnosis' category (p < 0.01); there was no difference in questions categorized as 'Fact' (p = 0.15) or 'Policy' (p = 0.22). Additional prompting improved ChatGPT response readability (FRE 55.6 ± 13.6, p < 0.01). CONCLUSIONS: ChatGPT outperforms web search in answering patient questions related to symptom-based diagnoses and is equivalent in providing medical facts and established policy. Appropriate prompting can further improve readability while maintaining accuracy. Further patient education is needed to relay the benefits and limitations of this technology as a source of medial information.

Comparison of digital recruitment strategies for Alzheimer's disease patients.

Objectives: Clinical trials studying Alzheimer's Disease (AD) face the challenge of recruiting participants with significant barriers to entering research studies. The objective of this study is to compare digital recruitment strategies' ability to recruit older adults with cognitive impairment (CI). Methods: Older adults with CI were recruited for a clinical trial studying vestibular therapy in reducing falls and improving balance and cognition in older adults with CI. Potential participants were recruited via two different digital recruitment methods, a direct messaging campaign using established patient records and a social media campaign. Potential participants then filled out surveys to determine eligibility for the study. Results: The direct messaging campaign contacted 3060 potential participants and the social media campaign resulted in 8265 instances of unique engagement. Of the number of people reached, the direct messaging campaign had a higher percentage of people who submitted the survey compared to the social media campaign (8.3% vs. 1.2%, p < 0.001). There was no significant difference in age, race, ethnicity, education, household income, and insurance status between the recruitment groups (p > 0.05). Direct messaging recruitment proved more cost-effective at $21.74 per eligible participant compared to the social media campaign at $859.58 per eligible participant. Conclusion: This study found that direct messaging recruitment using established patient records was more cost-effective compared to social media recruitment for this clinical trial. In this sample size, similar demographics were reached by both recruitment methods. Future studies should continue to explore the use of social media and alternative methods to recruit representative participant populations for ongoing AD research.

Local spatial navigation or "steering" in patients with vestibular loss in a virtual reality environment.

BACKGROUND: Patients with vestibular loss have reduced wayfinding ability, but the association between vestibular loss and impaired steering spatial navigation is unclear. OBJECTIVE: To evaluate whether vestibular loss is associated with reduced steering navigation performance in a virtual reality (VR) environment containing obstacles. METHODS: 17 ambulatory adults with vestibular loss were age/sex-matched to healthy controls. Participants traversed a VR hallway with obstacles, and their navigation performance was compared using metrics such as collisions, time, total distance travelled, and speed in single and multivariate analysis. RESULTS: In univariate analysis there was no significant difference in collisions between vestibular patients and controls (1.84 vs. 2.24, p = 0.974). However, vestibular patients took more time, longer routes, and had lower speeds to complete the task (56.9 vs. 43.9 seconds, p < 0.001; 23.1 vs. 22.0 meters, p = 0.0312; 0.417 vs. 0.544 m/s, p < 0.001). These results were confirmed in multivariate analysis. CONCLUSIONS: This study found that patients with vestibular loss displayed slower gait speeds and traveled longer distances, though did not make more collisions, during a VR steering navigation task. Beyond the known influence of vestibular function on gait speed, vestibular loss may also contribute to less efficient steering navigation through an obstacle-laden environment, through neural mechanisms that remain to be elucidated.

Quantitative vestibular assessment: The development and validation of a novel, remote video head impulse test against in-clinic measurements.

Objectives: To develop a novel remote head impulse test (rHIT), and to provide preliminary data validating the rHIT vestibular-ocular reflex (VOR) gains against the in-clinic vHIT. Methods: A convenience sample of 10 patients referred for vestibular assessment at our institution was recruited. In-clinic vHIT was used to quantify lateral VOR gains. Patients subsequently underwent an rHIT protocol, whereby patients performed active, lateral head rotations while their eyes and heads were recorded using a laptop camera and video-conferencing software. The vHIT and rHIT VOR gains were compared using paired t-tests, and a Pearson correlation coefficient between the gains was calculated. Absolute accuracy, sensitivity, and specificity of the rHIT were additionally calculated. Results: Of the 10 patients recruited, 4 were male, and the average ± standard deviation (SD) age was 61.4 ± 15.3 years. As determined by the vHIT, 2 patients had normal bilateral VOR gains, 6 with unilateral vestibular hypofunction, and 2 with bilateral vestibular hypofunction. The correlation between the rHIT and vHIT gains was 0.73 (p < .001). The rHIT exhibited an absolute accuracy of 75.0%, sensitivity of 70.0%, and specificity of 80.0%. When ears had a vHIT VOR gain less than 0.40, the rHIT exhibited 100.0% accuracy. Conversely, 60.0% of deficient ears with vHIT VOR gains greater than 0.40 were incorrectly categorized by the rHIT. Conclusion: The rHIT may be better suited for detecting more severe vestibular deficiencies. Future iterations of the rHIT should aim to increase the video frame-rate capabilities to detect subtler VOR impairments. Level of Evidence: 4.

Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery.

Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019-2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9-8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6-7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63-0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01-0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.

BRAF V600E-Mutant Glioblastoma with Extracranial Metastases Responsive to Combined BRAF and MEK Targeted Inhibition: A Case Report.

Recent advancements in understanding the biology of glioblastomas (GBM) and increasing adoption of genomic sequencing in oncology practice have led to the discovery of several targetable mutations in these cancers. Among them, the BRAF V600E mutation can be found in approximately 3% of GBM. Despite the aggressive nature of GBM, metastatic disease is rarely observed. While there are growing data utilizing BRAF-targeting strategies in patients with GBM, data examining their efficacy in cases of metastatic GBM are lacking. We present the case of a 46-year-old female with GBM, isocitrate dehydrogenase (IDH)-wildtype and O6-methylguanine-DNA methyltransferase promoter (MGMT) unmethylated, BRAF V600E-mutant, and MYC amplified with extra-central nervous system spread to the spine and lung. Four months after completion of treatment with standard chemoradiation and temozolomide, the patient developed severe back pain, leading to the eventual discovery of her metastatic disease. Based on the presence of the BRAF V600E mutation, the patient was treated with and achieved an intracranial and systemic response to combination BRAF-MEK targeted inhibition for 9 months before evidence of progression.

Challenges in the Treatment of Newly Diagnosed and Recurrent Primary Central Nervous System Lymphoma.

Primary central nervous system lymphomas (PCNSLs) are rare cancers of the central nervous system (CNS) and are predominantly diffuse large B-cell lymphomas of the activated B-cell (ABC) subtype. They typically present in the sixth and seventh decade of life, with the highest incidence among patients aged >75 years. Although many different regimens have demonstrated efficacy in newly diagnosed and relapsed or refractory PCNSL, there have been few randomized prospective trials, and most recommendations and treatment decisions are based on single-arm phase II trials or even retrospective studies. High-dose methotrexate (HD-MTX; 3-8 g/m2) is the backbone of preferred standard induction regimens. Various effective regimens with different toxicity profiles can be considered that combine other chemotherapies and/or rituximab with HD-MTX, but there is currently no consensus for a single preferred regimen. There is controversy about the role of various consolidation therapies for patients who respond to HD-MTX-based induction therapy. For patients with relapsed or refractory PCNSL who previously experienced response to HD-MTX, repeat treatment with HD-MTX-based therapy can be considered depending on the timing of recurrence. Other more novel and less toxic regimens have been developed that show efficacy in recurrent disease, including ibrutinib, or lenalidomide ± rituximab. There is uniform agreement to delay or avoid whole-brain radiation therapy due to concerns for significant neurotoxicity if a reasonable systemic treatment option exists. This article aims to provide a clinically practical approach to PCNSL, including special considerations for older patients and those with impaired renal function. The benefits and risks of HD-MTX or high-dose chemotherapy with autologous stem cell transplantation versus other, better tolerated strategies are also discussed. In all settings, the preferred treatment is always enrollment in a clinical trial if one is available.

Corticotropin Releasing Factor Type 1 and 2 Receptor Signaling in the Medial Prefrontal Cortex Modulates Binge-Like Ethanol Consumption in C57BL/6J Mice.

Corticotropin releasing factor (CRF) signaling via limbic CRF1 and 2 receptors (CRF1R and CRF2R, respectively) is known to modulate binge-like ethanol consumption in rodents. Though CRF signaling in the medial prefrontal cortex (mPFC) has been shown to modulate anxiety-like behavior and ethanol seeking, its role in binge ethanol intake is unknown. Here, we used "drinking-in-the-dark" (DID) procedures in male and female C57BL/6J mice to address this gap in the literature. First, the role of CRF1R and CRF2R signaling in the mPFC on ethanol consumption was evaluated through site-directed pharmacology. Next, we evaluated if CRF1R antagonist reduction of binge-intake was modulated in part through CRF2R activation by co-administration of a CRF1R and CRF2R antagonist. Intra-mPFC inhibition of CRF1R and activation of CRF2R resulted in decreased binge-like ethanol intake. Further, the inhibitory effect of the CRF1R antagonist was attenuated by co-administration of a CRF2R antagonist. We provide novel evidence that (1) inhibition of CRF1R or activation of CRF2R in the mPFC reduces binge-like ethanol intake; and (2) the effect of CRF1R antagonism may be mediated via enhanced CRF2R activation. These observations provide the first direct behavioral pharmacological evidence that CRF receptor activity in the mPFC modulates binge-like ethanol consumption.

Medial prefrontal cortex neuropeptide Y modulates binge-like ethanol consumption in C57BL/6J mice.

Neuropeptide Y (NPY) signaling via limbic NPY1 and 2 receptors (NPY1R and NPY2R, respectively) is known to modulate binge-like ethanol consumption in rodents. However, the role of NPY signaling in the medial prefrontal cortex (mPFC), which provides top-down modulation of the limbic system, is unknown. Here, we used "drinking-in-the-dark" (DID) procedures in C57BL/6J mice to address this gap in the literature. First, the impact of DID on NPY immunoreactivity (IR) was assessed in the mPFC. Next, the role of NPY1R and NPY2R signaling in the mPFC on ethanol consumption was evaluated through site-directed pharmacology. Chemogenetic inhibition of NPY1R+ neurons in the mPFC was performed to further evaluate the role of this population. To determine the potential role of NPY1R+ neurons projecting from the mPFC to the basolateral amygdala (BLA) this efferent population was selectively silenced. Three, 4-day cycles of DID reduced NPY IR in the mPFC. Intra-mPFC activation of NPY1R and antagonism of NPY2R resulted in decreased binge-like ethanol intake. Silencing of mPFC NPY1R+ neurons overall, and specifically NPY1R+ neurons projecting to the BLA, significantly reduced binge-like ethanol intake. We provide novel evidence that (1) binge-like ethanol intake reduces NPY levels in the mPFC; (2) activation of NPY1R or blockade of NPY2R reduces binge-like ethanol intake; and (3) chemogenetic inhibition of NPY1R+ neurons in the mPFC and NPY1R+ mPFC neurons projecting to the BLA blunts binge-like drinking. These observations provide the first direct evidence that NPY signaling in the mPFC modulates binge-like ethanol consumption.