Up beating skull vibration induced nystagmus in a case of bilateral sequential superior branch vestibular neuritis.

Vestibular neuritis is one of the most common reasons that someone may experience an episode of acute spontaneous vertigo, with the majority cases impacting only one ear. Cases of bilateral vestibular neuritis are rare and are thought to account for less than 10% of all cases of vestibular neuritis. 18,1,9,15,12 Skull vibration testing is an efficient means to screen for asymmetry in vestibular function but is still in its infancy in clinical use. The ideal assessment methods and the typical patterns of skull vibration induced nystagmus are relatively well understood, however, the presentation of skull vibration induced nystagmus in atypical labyrinthine pathology is less clear. Skull vibration induces a horizontal nystagmus that beats toward the healthy labyrinth in most instances of significant labyrinthine asymmetry. We pose a case report of a patient that's symptomology and clinical test findings are most consistent with bilateral sequential superior branch vestibular neuritis with an up beating skull vibration induced nystagmus.

Persistent Postural Perceptual Dizziness (PPPD) induced by caloric testing: a case report.

The condition of PPPD is a common chronic vestibular disorder that is thought to be due to a central vestibular maladaptation. The condition is frequently encountered in those with a history of migraine, anxiety or panic attacks. Many cases of PPPD are preceded by vestibular disorders with vestibular migraine thought to precede at least 20% of cases.1 Those with a history of migraine have been shown to have difficulties with sensory integration, habituation and intolerance to stimuli. This often leads to discomfort associated with some vestibular test procedures. We pose a case report of a patient with a history of migraine that developed new onset PPPD following caloric irrigations.

Child protective services during COVID-19 and doubly marginalized children: International perspectives.

BACKGROUND: Alongside deficits in children's wellbeing, the COVID-19 pandemic has created an elevated risk for child maltreatment and challenges for child protective services worldwide. Therefore, some children might be doubly marginalized, as prior inequalities become exacerbated and new risk factors arise. OBJECTIVE: To provide initial insight into international researchers' identification of children who might have been overlooked or excluded from services during the pandemic. PARTICIPANTS AND SETTING: This study was part of an international collaboration involving researchers from Brazil, Canada, Colombia, Israel, South Africa, Uganda, the UK and the USA. Researchers from each country provided a written narrative in response to the three research questions in focus, which integrated the available data from their countries. METHOD: Three main questions were explored: 1) Who are the children that were doubly marginalized? 2) What possible mechanisms may be at the root? and 3) In what ways were children doubly marginalized? The international scholars provided information regarding the three questions. A thematic analysis was employed using the intersectional theoretical framework to highlight the impact of children's various identities. RESULTS: The analysis yielded three domains: (1) five categories of doubly marginalized children at increased risk of maltreatment, (2) mechanisms of neglect consisting of unplanned, discriminatory and inadequate actions, and (3) children were doubly marginalized through exclusion in policy and practice and the challenges faced by belonging to vulnerable groups. CONCLUSION: The COVID-19 pandemic can be used as a case study to illustrate the protection of children from maltreatment during worldwide crises. Findings generated the understanding that child protective systems worldwide must adhere to an intersectionality framework to protect all children and promote quality child protection services.

Coding and Reimbursement for Vestibular Tests by the U.S. Centers for Medicare and Medicaid Services (CMS).

Coding and insurance reimbursement is a part of the healthcare system in the United States but is subject to periodic modifications. In addition to changes in the evaluation and management (E/M) codes that took effect in 2021, there are some differences in coding for some diagnostic vestibular function test procedures. Two new codes for vestibular myogenic evoked potential testing were added and previous codes for auditory evoked potential codes 92585 and 92586, which some facilities had used to bill for vestibular myogenic evoked potential testing, have been eliminated. This article outlines the current state of coding and reimbursement by CMS for vestibular procedures.

Crohn's Disease Remission with a Plant-Based Diet: A Case Report.

Crohn's disease (CD) is a form of chronic inflammatory bowel disease (IBD). The etiology of CD is thought to be multi-factorial; genetic factors, dietary and environmental exposures, immune events, and dysfunction of the gut microbiome are all though to play a role. The prevalence of CD is increasing globally and is higher in countries with a Westernized diet and lifestyle. Several human trials have demonstrated that plant-based dietary therapies may have utility in both the treatment of acute CD flares and the maintenance of remission. This case study describes a young adult male with newly diagnosed CD who failed to enter clinical remission despite standard medical therapy. After switching to a diet based exclusively on grains, legumes, vegetables, and fruits, he entered clinical remission without need for medication and showed no signs of CD on follow-up colonoscopy.

Effect of phylloquinone (vitamin K1) supplementation for 12 months on the indices of vitamin K status and bone health in adult patients with Crohn's disease.

Although epidemiological findings support a role for vitamin K status in the improvement of bone indices in adult patients with Crohn's disease (CD), this needs to be confirmed in double-blind, randomised controlled trials (RCT) with phylloquinone (vitamin K1). By conducting two RCT, the present study aimed to first establish whether supplementation with 1000 µg of phylloquinone daily near-maximally suppresses the percentage of undercarboxylated osteocalcin in serum (%ucOC; marker of vitamin K status) in adult patients with CD currently in remission as it does in healthy adults and second determine the effect of supplementation with phylloquinone at this dose for 12 months on the indices of bone turnover and bone mass. The initial dose-ranging RCT was conducted in adult patients with CD (n 10 per group) using 0 (placebo), 1000 or 2000 µg of phylloquinone daily for 2 weeks. In the main RCT, the effect of placebo v. 1000 µg vitamin K/d (both co-administered with Ca (500 mg/d) and vitamin D3 (10 µg/d)) for 12 months (n 43 per group) on the biochemical indices of bone turnover (determined by enzyme immunoassay) and bone mass (determined by dual-energy X-ray absorptiometry) were investigated. At baseline, the mean %ucOC was 47 %, and this was suppressed upon supplementation with 1000 µg of phylloquinone daily ( - 81 %; P< 0·01) and not suppressed further by 2000 µg of phylloquinone daily. Compared with the placebo, supplementation with 1000 µg of phylloquinone daily for 12 months had no significant effect (P>0·1) on bone turnover markers or on the bone mass of the lumbar spine or femur, but modestly increased (P< 0·05) the bone mass of the total radius. Despite near maximal suppression of serum %ucOC, supplementation with 1000 µg of phylloquinone daily (with Ca and vitamin D3) had no effect on the indices of bone health in adult CD patients with likely vitamin K insufficiency.

The utilisation and diagnostic yield of radiological imaging in a specialist functional GI disorder clinic: an 11-year retrospective study.

OBJECTIVES: The term functional gastrointestinal disorders (FGID) describes various aggregations of chronic gastrointestinal (GI) symptoms not explained by identifiable organic pathology; accordingly, their diagnosis rests on symptom-based criteria and a process of exclusion. Evidence is lacking on the appropriate use of abdominal imaging studies (AIS) in FGIDs. METHODS: We investigated the utilisation of AIS (site, modality, diagnostic yield/significance) at a tertiary FGID clinic over an 11-year period. RESULTS: Of 1,621 patients, 507 (31%; 67.5% women, mean age 43.9 ± 17.37 years) referred from primary care had 997 AIS (1.7 per patient): ultrasonography (US) 36.1%, fluoroscopy (FLS) 28.8%, computed tomography (CT) 19.6%, plain radiography (PR) 13.5%, nuclear medicine (NM) 1%). Of the 997 AIS, 55.6% (554/997) were normal. Of the AIS with positive findings, 9.9% (62/625) were deemed 'probably significant' and 14.7% (92/625) 'significant'. Of the CT and FLS studies, 12.3% and 13.6%, respectively, yielded 'significant' abnormalities compared to 2.2% of the US studies and 2.1% of the PR studies. CT identified five of seven neoplasms, associated with male sex, increasing age and symptom onset after age 50 years. CONCLUSIONS: This study confirmed low use of AIS in tertiary FGID clinics and a high proportion of normal studies. Barium swallow/meal and CT were more likely to identify 'probably significant' or 'significant' findings, including neoplasms. KEY POINTS: Imaging referral rates from a specialist functional gastrointestinal disorder clinic are low. Despite this, normal studies are still frequent in those who are imaged. Ultrasonography was the most frequent investigation, yet yielded significant findings infrequently. Abdominal radiographs accounted for 13.5% of investigations yet were normal in 71.8 %. CT and fluoroscopy were more likely to yield positive findings.

Detection of Mycobacterium avium subspecies paratuberculosis in patients with Crohn's disease is unrelated to the presence of single nucleotide polymorphisms rs2241880 (ATG16L1) and rs10045431 (IL12B).

Mycobacterium avium subspecies paratuberculosis (MAP) has been controversially linked with Crohn's disease (CD). Detection of MAP in CD has been highly variable, and one explanation might be the genetic heterogeneity of this syndrome. Many of the single nucleotide polymorphisms (SNPs) linked with CD are contained within genes that are associated with bacterial handling in general, and some are specifically implicated in susceptibility to mycobacterial disease. We tested a cohort of IBD patients (n = 149) to determine whether the presence of MAP was associated with a selection of these SNPs. Blood samples from CD patients (n = 84), ulcerative colitis (UC, n = 65) patients and healthy controls (n = 55) were examined for the presence of MAP and SNPs in ATG16L1, IL12B, NOD2/CARD15, NKx2-3, IL23R and IRGM. Statistical analysis was then used to determine whether there was any association between the presence of MAP and these SNPs. MAP, rs2241880 (ATG16L1) and rs10045431 (IL12B) were found to be significantly associated with CD. The presence of MAP was not related to the status of the SNPs in ATG16L1 or IL12B. We have found no evidence for the contribution of these SNPs to the presence of MAP in CD patients.

Computed tomography assessment of intestinal gas volumes in functional gastrointestinal disorders.

BACKGROUND/AIMS: Many patients with functional gastrointestinal disorders (FGIDs) rank sensations of bloating and distension among their most debilitating symptoms. Previous studies that have examined intestinal gas volume (IGV) in patients with FGIDs have employed a variety of invasive and imaging techniques. These studies are limited by small numbers and have shown conflicting results. The aim of our study was to estimate, using CT of the abdomen and pelvis (CTAP), IGV in patients attending FGID clinic and to compare IGV in patients with and without FGID. METHODS: All CTAP (n = 312) performed on patients (n = 207) attending a specialized FGID clinic over 10-year period were included in this study. Patients were classified into one of 3 groups according to the established clinical grading system, as organic gastrointestinal disorder (OGID, ie, patients with an organic non-functional disorder, n = 84), FGID (n = 36) or organic and functional gastrointestinal disorder (OFGID, ie, patients with an organic and a functional disorder, n = 87). Two independent readers blinded to the diagnostic group calculated IGV using threshold based 3D region growing with OsiriX. RESULTS: Median IGVs for the FGID, OGID, and OFGID groups were 197.6, 220.6 and 155.0 mL, respectively. Stepwise linear regression revealed age at study, gender, and calculated body mass index to predict the log IGV with an r(2) of 0.116, and P < 0.001. There was a significant positive correlation between age and IGV in OGID (Spearman's = 0.253, P = 0.02) but this correlation was non-significant in the other groups. CONCLUSIONS: Although bloating is a classic symptom in FGID patients, IGV may not be increased compared with OGID and OFGID patients.

Diagnostic accuracy of computed tomography using lower doses of radiation for patients with Crohn's disease.

BACKGROUND & AIMS: Magnetic resonance and ultrasonography have increasing roles in the initial diagnosis of Crohn's disease, but computed tomography (CT) with positive oral contrast agents is most frequently used to identify those with acute extramural complications. However, CT involves exposure of patients to radiation. We prospectively compared the diagnostic accuracy of low-dose CT (at a dose comparable to that used to obtain an abdominal radiograph) with conventional-dose CT in patients with active Crohn's disease. METHODS: Low and conventional dose CT of the abdomen and pelvis were acquired from 50 patients with Crohn's disease, referred from an inflammatory bowel disease service (20 male; median age, 34 years). Acute complications of Crohn's disease were suspected. Iterative reconstruction was performed on all CT datasets to facilitate dose reduction. Three radiologists reviewed the low-dose CT images before the conventional-dose CT images. RESULTS: The median effective dose (interquartile range) of radiation for the low-dose CT was reduced by 72% from that of conventional CT: from 3.5 mSv (3-5.08 mSv) to 0.98 mSv (0.77-1.42 mSv) (P < .001). As expected, the quality indexes of the low-dose images were inferior to those of the conventional-dose images, but no clinically significant diagnostic findings were missed with low-dose imaging. Follow-up CT examinations were recommended for 5 patients; 1 had a cervical tumor, 1 had a pancreatic lesion, and 3 had intra-abdominal abscess. In each case, the image obtained by low-dose CT was considered sufficient for diagnosis. CONCLUSIONS: Although low-dose CT images are of lower quality than images obtained with conventional doses of radiation, no clinically significant diagnostic findings were missed from low-dose CT images of patients with Crohn's disease. The low-dose CT was obtained at a median effective dose equivalent to 1.4 abdominal radiographs.

Selection of symptomatic patients with Crohn's disease for abdominopelvic computed tomography: role of serum C-reactive protein.

BACKGROUND: Results of previous studies have shown that repeated abdominopelvic computed tomography (CT) examinations can lead to substantial cumulative diagnostic radiation exposure in patients with Crohn's disease (CD). Improved selection of patients referred for CT will reduce unnecessary radiation exposure. This study examines if serum C-reactive protein (CRP) concentration predicts which symptomatic patients with CD are likely to have significant disease activity or disease complications (such as abscess) detected on abdominopelvic CT. METHODS: All abdominopelvic CTs performed on patients with CD at a tertiary referral centre during the period June 2003 to June 2008 were identified. CT findings were coded by a pair of independent blinded senior radiologists for (i) small bowel luminal disease, (ii) large bowel luminal disease, (iii) mesenteric inflammatory changes, (iv) penetrating disease (fistulas, abscess, or phlegmon), (v) acute disease complications (obstruction or perforation), and (vi) acute non-CD findings. Imaging findings were correlated with serum CRP checked within 14 days before imaging. The reference range for CRP was defined as 0-5 mg/L. RESULTS: A total of 147 patients with symptomatic CD had a CRP assay performed within 14 days before undergoing abdominopelvic CT. The median time from CRP assay to imaging was 2 days (interquartile range, 0-6 days). Median CRP before imaging was 24 mg/L (interquartile range, 6-88 mg/L). CT was normal in 34 of 147 case (23.1%). Patients with normal CRP (n = 36) were significantly less likely to have penetrating disease (odds ratio [OR], 0.04 [95% confidence interval {CI}, 0.01-0.7]; P < .001) or large bowel luminal disease (OR, 0.3 [95% CI, 0.1-0.8]; P < .05). Normal CRP excluded penetrating disease with a sensitivity of 1.0 (95% CI, 0.87-1.0). CRP levels did not correlate with the presence of small bowel luminal disease (n = 82), mesenteric inflammatory changes (n = 68), or acute disease complications (n = 10). CONCLUSION: Symptomatic patients with CD and normal serum CRP are unlikely to have evidence of abscess, fistulating disease, or large bowel luminal disease detected on abdominopelvic CT. However, abdominopelvic CT may demonstrate evidence of clinically significant non-penetrating CD or complications, including perforation and acute obstruction, regardless of serum CRP concentration.

Radiation exposure from diagnostic imaging among patients with gastrointestinal disorders.

BACKGROUND & AIMS: There are concerns about levels of radiation exposure among patients who undergo diagnostic imaging for inflammatory bowel disease (IBD), compared with other gastrointestinal (GI) disorders. We quantified imaging studies and estimated the cumulative effective dose (CED) of radiation received by patients with organic and functional GI disorders. We also identified factors and diagnoses associated with high CEDs. METHODS: We analyzed data from 2590 patients who were diagnosed with GI disorders at a tertiary gastroenterology center from January 1999-January 2009 on the basis of International Statistical Classification of Diseases and Health-related Problems, 10th revision and Rome III criteria. High annual CED and high total CED were defined as figures exceeding the 90th percentile for the population. RESULTS: Diagnostic imaging was performed on 57% of the patients (1429 of 2509). High annual CEDs (>9.6 millisieverts/annum) were independently associated with Crohn's disease (odds ratio [OR], 5.3; P < .0001), organic small bowel disease (OR, 2.6; P < .005), and functional disorders of childhood and adolescence (OR, 9.8; P < .005). High total CEDs (>30.8 millisieverts) were independently associated with Crohn's disease (OR, 81.9; P < .0001), ulcerative colitis (OR, 19.0; P < .0001), indeterminate colitis (OR, 7.5; P < .0005), and the following non-IBD diagnoses: organic small bowel disorders (OR, 12.5; P < .0001), organic hepatic disorders (OR, 3.6; P < .01), and functional disorders of childhood and adolescence (OR, 13.8; P = .02). CONCLUSIONS: Higher levels of annual and total diagnostic radiation exposure are associated with IBD and with other organic and functional GI disorders. Evidence-based guidelines for image analysis of patients with organic and functional gastrointestinal disorders, especially those that reduce radiation exposure, are needed.

Clinical practice guideline: benign paroxysmal positional vertigo.

OBJECTIVES: This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV. PURPOSE: The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology-head and neck surgery, physical therapy, and physical medicine and rehabilitation. RESULTS: The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV. DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.