Vestibular rehabilitation for peripheral vestibular hypofunction: An updated clinical practice guideline from the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

BACKGROUND: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual\u27s quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. METHODS: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. RESULTS: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes. DISCUSSION: Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction. LIMITATIONS: The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction. DISCLAIMER: These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369)

The Impact of Winter Storms on Sediment Transport Through a Narrow Strait, Bohai, China

The Yellow River is one of the most significant sources of terrestrial sediment to the global seas, and the Bohai Strait is the only pathway that delivers Yellow River‐derived sediments from the shallow Bohai Sea to the Yellow Sea. To investigate sediment transport processes through the strait under the influence of storms (strong northerly winds) that frequently occur in winter, we deployed two sets of observing platforms equipped with Acoustic Doppler Current Profilers (ADCP) and a suite of other sensors in the strait in January 2018. Aided by a system of high‐resolution models, we reconstructed sediment dynamics in response to the strong northerly wind of a winter storm. Model results show that the instantaneous suspended sediment flux (SSF) is highly aligned with tidal currents, while the net sediment flux has a clear dependence on variations in exchange flow and sediment resuspension. Enhanced coastal currents, intensified wave motions, and higher suspended sediment concentrations indicate that the through‐strait sediment flux during outflows is greater than during inflow conditions. Such SSF asymmetries are believed responsible for the net sediment export through the Bohai Strait in wintertime. Diagnostic analyses provided insights into the dynamic mechanisms of exchange flow variations influenced by both the strong northerly winds and the wind‐triggered coastal trapped waves in the shallow, narrow strait via geostrophic effects. This study highlights the importance of storm‐induced horizontal exchange processes in a coupled bay‐shelf system

Data-Driven, Multi-Model Workflow Suggests Strong Influence from Hurricanes on the Generation of Turbidity Currents in the Gulf of Mexico

Turbidity currents deliver sediment rapidly from the continental shelf to the slope and beyond; and can be triggered by processes such as shelf resuspension during oceanic storms; mass failure of slope deposits due to sediment- and wave-pressure loadings; and localized events that grow into sustained currents via self-amplifying ignition. Because these operate over multiple spatial and temporal scales, ranging from the eddy-scale to continental-scale; coupled numerical models that represent the full transport pathway have proved elusive though individual models have been developed to describe each of these processes. Toward a more holistic tool, a numerical workflow was developed to address pathways for sediment routing from terrestrial and coastal sources, across the continental shelf and ultimately down continental slope canyons of the northern Gulf of Mexico, where offshore infrastructure is susceptible to damage by turbidity currents. Workflow components included: (1) a calibrated simulator for fluvial discharge (Water Balance Model - Sediment; WBMsed); (2) domain grids for seabed sediment textures (dbSEABED); bathymetry, and channelization; (3) a simulator for ocean dynamics and resuspension (the Regional Ocean Modeling System; ROMS); (4) A simulator (HurriSlip) of seafloor failure and flow ignition; and (5) A Reynolds-averaged Navier–Stokes (RANS) turbidity current model (TURBINS). Model simulations explored physical oceanic conditions that might generate turbidity currents, and allowed the workflow to be tested for a year that included two hurricanes. Results showed that extreme storms were especially effective at delivering sediment from coastal source areas to the deep sea, at timescales that ranged from individual wave events (~hours), to the settling lag of fine sediment (~days)

Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices

BACKGROUND: Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata. METHODS: We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES. RESULTS: We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine. CONCLUSIONS: Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017

Sediment dynamics in the Adriatic Sea investigated with coupled models

Several large research programs focused on the Adriatic Sea in winter 2002-2003, making it an exciting place for sediment dynamics modelers (Figure 1). Investigations of atmospheric forcing and oceanic response (including wave generation and propagation, water-mass formation, stratification, and circulation), suspended material, bottom boundary layer dynamics, bottom sediment, and small-scale stratigraphy were performed by European and North American researchers participating in several projects. The goal of EuroSTRATAFORM researchers is to improve our ability to understand and simulate the physical processes that deliver sediment to the marine environment and generate stratigraphic signatures. Scientists involved in the Po and Apennine Sediment Transport and Accumulation (PASTA) experiment benefited from other major research programs including ACE (Adriatic Circulation Experiment), DOLCE VITA (Dynamics of Localized Currents and Eddy Variability in the Adriatic), EACE (the Croatian East Adriatic Circulation Experiment project), WISE (West Istria Experiment), and ADRICOSM (Italian nowcasting and forecasting) studies

Development of the CSOMIO Coupled Ocean-Oil-Sediment- Biology Model

The fate and dispersal of oil in the ocean is dependent upon ocean dynamics, as well as transformations resulting from the interaction with the microbial community and suspended particles. These interaction processes are parameterized in many models limiting their ability to accurately simulate the fate and dispersal of oil for subsurface oil spill events. This paper presents a coupled ocean-oil-biology-sediment modeling system developed by the Consortium for Simulation of Oil-Microbial Interactions in the Ocean (CSOMIO) project. A key objective of the CSOMIO project was to develop and evaluate a modeling framework for simulating oil in the marine environment, including its interaction with microbial food webs and sediments. The modeling system developed is based on the Coupled Ocean-Atmosphere-Wave-Sediment Transport model (COAWST). Central to CSOMIO’s coupled modeling system is an oil plume model coupled to the hydrodynamic model (Regional Ocean Modeling System, ROMS). The oil plume model is based on a Lagrangian approach that describes the oil plume dynamics including advection and diffusion of individual Lagrangian elements, each representing a cluster of oil droplets. The chemical composition of oil is described in terms of three classes of compounds: saturates, aromatics, and heavy oil (resins and asphaltenes). The oil plume model simulates the rise of oil droplets based on ambient ocean flow and density fields, as well as the density and size of the oil droplets. The oil model also includes surface evaporation and surface wind drift. A novel component of the CSOMIO model is two-way Lagrangian-Eulerian mapping of the oil characteristics. This mapping is necessary for implementing interactions between the ocean-oil module and the Eulerian sediment and biogeochemical modules. The sediment module is a modification of the Community Sediment Transport Modeling System. The module simulates formation of oil-particle aggregates in the water column. The biogeochemical module simulates microbial communities adapted to the local environment and to elevated concentrations of oil components in the water column. The sediment and biogeochemical modules both reduce water column oil components. This paper provides an overview of the CSOMIO coupled modeling system components and demonstrates the capabilities of the modeling system in the test experiments

Cohesive and mixed sediment in the Regional Ocean Modeling System (ROMS v3.6) implemented in the Coupled Ocean-Atmosphere-Wave-Sediment Transport Modeling System (COAWST r1234)

We describe and demonstrate algorithms for treating cohesive and mixed sediment that have been added to the Regional Ocean Modeling System (ROMS version 3.6), as implemented in the Coupled Ocean-Atmosphere-Wave- Sediment Transport Modeling System (COAWST Subversion repository revision 1234). These include the following: floc dynamics (aggregation and disaggregation in the water column); changes in floc characteristics in the seabed; erosion and deposition of cohesive and mixed (combination of cohesive and non-cohesive) sediment; and biodiffusive mixing of bed sediment. These routines supplement existing noncohesive sediment modules, thereby increasing our ability to model fine-grained and mixed-sediment environments. Additionally, we describe changes to the sediment bed layering scheme that improve the fidelity of the modeled stratigraphic record. Finally, we provide examples of these modules implemented in idealized test cases and a realistic application

The LARP1 La-Module recognizes both ends of TOP mRNAs

La-Related Protein 1 (LARP1) is an RNA-binding protein that regulates the stability and translation of mRNAs encoding the translation machinery, including ribosomal proteins and translation factors. These mRNAs are characterized by a 5ʹ-terminal oligopyrimidine (TOP) motif that coordinates their temporal and stoichiometric expression. While LARP1 represses TOP mRNA translation via the C-terminal DM15 region, the role of the N-terminal La-Module in the recognition and translational regulation of TOP mRNAs remains elusive. Herein we show that the LARP1 La-Module also binds TOP motifs, although in a cap-independent manner. We also demonstrate that it recognizes poly(A) RNA. Further, our data reveal that the LARP1 La-Module can simultaneously engage TOP motifs and poly(A) RNA. These results evoke an intriguing molecular mechanism whereby LARP1 could regulate translation and stabilization of TOP transcripts