Diagnostic accuracy and usability of the EMBalance decision support system for vestibular disorders in primary care: proof of concept randomised controlled study results.

BACKGROUND: Dizziness and imbalance are common symptoms that are often inadequately diagnosed or managed, due to a lack of dedicated specialists. Decision Support Systems (DSS) may support first-line physicians to diagnose and manage these patients based on personalised data. AIM: To examine the diagnostic accuracy and application of the EMBalance DSS for diagnosis and management of common vestibular disorders in primary care. METHODS: Patients with persistent dizziness were recruited from primary care in Germany, Greece, Belgium and the UK and randomised to primary care clinicians assessing the patients with (+ DSS) versus assessment without (- DSS) the EMBalance DSS. Subsequently, specialists in neuro-otology/audiovestibular medicine performed clinical evaluation of each patient in a blinded way to provide the "gold standard" against which the + DSS, - DSS and the DSS as a standalone tool (i.e. without the final decision made by the clinician) were validated. RESULTS: One hundred ninety-four participants (age range 25-85, mean = 57.7, SD = 16.7 years) were assigned to the + DSS (N = 100) and to the - DSS group (N = 94). The diagnosis suggested by the + DSS primary care physician agreed with the expert diagnosis in 54%, compared to 41.5% of cases in the - DSS group (odds ratio 1.35). Similar positive trends were observed for management and further referral in the + DSS vs. the - DSS group. The standalone DSS had better diagnostic and management accuracy than the + DSS group. CONCLUSION: There were trends for improved vestibular diagnosis and management when using the EMBalance DSS. The tool requires further development to improve its diagnostic accuracy, but holds promise for timely and effective diagnosis and management of dizzy patients in primary care. TRIAL REGISTRATION NUMBER: NCT02704819 (clinicaltrials.gov).

Central Positional Nystagmus: A Systematic Literature Review.

OBJECTIVE: To provide a systematic review of the clinical and radiological features of lesion-induced central positional nystagmus (CPN) and identify salient characteristics that differentiate central from peripheral positional nystagmus (PN). METHODS: Systematic literature search according to the preferred reporting items for systematic reviews and meta-analysis. RESULTS: A total of 82 patients from 28 studies met the participants intervention, comparison, outcomes, and study designs criteria for inclusion. An atypical direction of nystagmus for the stimulated canal was reported in 97.5% patients during Dix-Hallpike (D-H) and 54.5% upon supine roll testing. Five types of CPNs were identified during positional testing: positional horizontal nystagmus (pHN) (36.8%), positional downbeating nystagmus (pDBN) (29.2%), positional torsional nystagmus (pTN) (2.1%), positional upbeating nystagmus (pUBN) (2.1%), and a combination of the four profiles (29.9%). CPN was paroxysmal (<60 s) in 85% patients on straight head hanging (SHH), 63.9% on D-H, and 37.5% on supine roll, and had a latency <3 s upon positioning in 94.7% patients in which it was reported. Concurrent vertigo was reportedly present in 63.4% patients and 48.8% demonstrated other neurological signs. Radiologically, in 74.4%, there was mention of cerebellar involvement, isolated brainstem involvement in 8.5%, and 14.6% involved the fourth ventricle. CONCLUSION: Currently, there is a lack of robust data on the clinical and radiological characteristics of CPN highlighting the need for better phenotyping of CPN to help differentiate this entity from peripheral causes of PN. With increased awareness of CPN, particularly in the acute setting, we may see a change in the estimated prevalence of CPN and improved clinical markers to promptly identify the frequently sinister underlying causes.

EMBalance - validation of a decision support system in the early diagnostic evaluation and management plan formulation of balance disorders in primary care: study protocol of a feasibility randomised controlled trial.

BACKGROUND: Balance problems are caused by multiple factors and often lead to falls and related fractures, bringing large socio-economic costs. The complexity of balance control mechanisms, the lack of medical expertise, and the absence of specialised equipment contribute to the delayed or incorrect diagnosis and management ofthese patients. Advances in computer science have allowed the development of computer systems that support clinical diagnosis and treatment decisions based on individualised patient data. The aim of the EMBalance decision support system (DSS) is to support doctors facing this clinical challenge, to make a definitive diagnosis and implement an effective management plan. The EMBalance study will determine the accuracy of this supportive tool when used by non-specialist doctors. This study is funded by the European Union's Seventh Framework Programme. METHODS/DESIGN: EMBalance is a proof-of-concept study designed as a non-commercial, international, multi-centre, single-blind, parallel-group randomised controlled trial to be carried out at four clinical sites in the United Kingdom, Germany, Greece and Belgium. The study is comprised of three stages: internal pilot, phase I (diagnosis) and stage II (management). For this purpose, 200 patients presenting with persistent dizziness (>3 months' duration) to primary care services will be randomised to either the intervention group (diagnostic assessment with the DSS) or a control group (diagnostic assessment without the DSS). Patients allocated to the intervention group will be assessed by a doctor with the support of the EMBalance DSS, while patients allocated to the control group will receive a visit as per standard practice. Ultimately, all patients' diagnoses and management plans will be certified by a consultant in neuro-otology. DISCUSSION: EMBalance is the first trial to test the accuracy of a DSS in both the diagnosis of and the management plan for vestibular disorders across the healthcare systems of four different countries. The EMBalance study is the result of a combined effort of engineers and physicians to develop an accurate tool to support non-specialist doctors, with no risk for the patient. This trial will provide reliable information about the benefits of implementing DSSs in primary care while supporting the feasibility of testing the EMBalance algorithms in further research. TRIAL REGISTRATION: ClinicalTrials.gov NCT02704819 . Registered 29 February 2016.

Using personal response systems to assess speech perception within the classroom: an approach to determine the efficacy of sound field amplification in primary school classrooms.

OBJECTIVES: The assessment of the combined effect of classroom acoustics and sound field amplification (SFA) on children's speech perception within the "live" classroom poses a challenge to researchers. The goals of this study were to determine: (1) Whether personal response system (PRS) hand-held voting cards, together with a closed-set speech perception test (Chear Auditory Perception Test [CAPT]), provide an appropriate method for evaluating speech perception in the classroom; (2) Whether SFA provides better access to the teacher's speech than without SFA for children, taking into account vocabulary age, middle ear dysfunction or ear-canal wax, and home language. DESIGN: Forty-four children from two school-year groups, year 2 (aged 6 years 11 months to 7 years 10 months) and year 3 (aged 7 years 11 months to 8 years 10 months) were tested in two classrooms, using a shortened version of the four-alternative consonant discrimination section of the CAPT. All children used a PRS to register their chosen response, which they selected from four options displayed on the interactive whiteboard. The classrooms were located in a 19th-century school in central London, United Kingdom. Each child sat at their usual position in the room while target speech stimuli were presented either in quiet or in noise. The target speech was presented from the front of the classroom at 65 dBA (calibrated at 1 m) and the presented noise level was 46 dBA measured at the center of the classroom. The older children had an additional noise condition with a noise level of 52 dBA. All conditions were presented twice, once with SFA and once without SFA and the order of testing was randomized. White noise from the teacher's right-hand side of the classroom and International Speech Test Signal from the teacher's left-hand side were used, and the noises were matched at the center point of the classroom (10sec averaging [A-weighted]). Each child's expressive vocabulary age and middle ear status were measured individually and each child's home language and any special educational needs were recorded. RESULTS: All children were able to use the PRS handsets, and the CAPT speech perception test was sufficiently sensitive to highlight differences in perception in the different listening conditions. Scores were higher in quiet than in any noise condition. Results showed that group performance was significantly better with SFA than without it. The main demographic predictor of performance was expressive vocabulary age. SFA gave more benefit to the poorer performers in the group. There were no significant effects on performance relating to middle ear status or home language; however, the size of the population was too small to be able to fully explore these aspects in greater detail. CONCLUSION: PRS together with the CAPT provides a sensitive measure for in situ speech perception testing within the classroom. Vocabulary age has a large effect on a child's ability to perceive the speech signal. SFA leads to improved speech perception, when the speech signal has been degraded because of poor acoustics or background noise and has a particularly large effect for children with lower vocabulary ages.