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The quality of spring water and its suitability for human consumption is determined by examining its physicochemical and microbiological characteristics. Preliminary investigations were conducted to determine the potability of seven traditionally used springs in the highly populated hill town of Bhaderwah in Union Territory of Jammu and Kashmir, India. The water analysis was performed for various physico-chemical and microbial parameters during April 2019-March 2020. Water temperature, TDS, EC, pH, DO, free CO 2 , total alkalinity, total hardness, Ca 2+ , Mg 2+ , Na + , K + , CO 3 2- , HCOֿ 3 , Cl‾, NOֿ 3, PO 4 3- , SO 4 2- , total coliforms, and thermotolerant coliforms were all measured. Eleven physical and chemical characteristics were used to generate the Water Quality Index. The Piper diagram demonstrated the predominance of Ca 2+ -HCOֿ 3 water types, whereas the Schoeller diagram indicated that all springs had a similar lithological origin. The chemical composition of springs tested met the required criteria for drinking water quality. The microbiological indicators, on the other hand, did not satisfy the criteria except for Eidgah spring, which lacked thermotolerant coliforms. Our results on spring water potability indicate that the town's most dependable springs are susceptible to anthropogenic contamination and therefore need treatment prior to use. Apart from frequent monitoring, the responsible municipal corporation is expected to develop comprehensive plans to rehabilitate and revitalise these vulnerable drinking water sources., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: Hospitalised patients are at risk of temporary or permanent loss of functioning which impacts their future independence. Implementation of a rehabilitative approach in everyday nursing in the acute care setting may produce good therapeutic results and promote independent daily living of patients. Thus, the aim of the study was to explore and understand the patterns of a rehabilitative approach in acute hospital wards from the perspective of interdisciplinary team members. Specifically, our aim was to identify the factors promoting and preventing a rehabilitative approach., Method: We conducted four focus group interviews with 21 participants, including multidisciplinary team members from acute hospital wards. Data were analysed with conventional inductive content analysis., Results: The findings highlighted that the rehabilitative approach, as a personal way of working and personal working attitude, was a part of comprehensive nursing. The main goals of the rehabilitative approach were to support the physical functioning of the patients and their independent initiative and individuality during clinical care in hospital ward. The promoting and preventing factors that influenced the development of the rehabilitative approach consisted of personal factors, organisational factors and the physical settings of the hospital wards., Conclusion: The findings of this study indicate that the rehabilitative approach in nursing focused on supporting the physical functioning, independence and self-confidence of the patient. The staff highlighted that interdisciplinary teamwork was one feature of the rehabilitative approach. The rehabilitative approach in nursing should be established as a part of everyday activity in clinical practice., (© 2021 Nordic College of Caring Science.)

Purpose of Review: This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN)., Recent Findings: Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies., Summary: DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Rainfall erosivity drives damaging hydrological events with significant environmental and socio-economic impacts. This study presents the world's hitherto longest time-series of annual rainfall erosivity (725-2019 CE), one from the Tiber River Basin (TRB), a fluvial valley in central Italy in which the city of Rome is located. A historical perspective of erosive floods in the TRB is provided employing a rainfall erosivity model based on documentary data, calibrated against a sample (1923-1964) of actual measurement data. Estimates show a notable rainfall erosivity, and increasing variability, during the Little Ice Age (here, ~ 1250-1849), especially after c. 1495. During the sixteenth century, erosive forcing peaked at > 3500 MJ mm hm -2  h -1  yr -1 in 1590, with values > 2500 MJ mm hm -2  h -1  yr -1 in 1519 and 1566. Rainfall erosivity continued into the Current Warm Period (since ~ 1850), reaching a maximum of ~ 3000 MJ mm hm -2  h -1  yr -1 in the 1940s. More recently, erosive forcing has attenuated, though remains critically high (e.g., 2087 and 2008 MJ mm hm -2  h -1  yr -1 in 1992 and 2005, respectively). Comparison of the results with sediment production (1934-1973) confirms the model's ability to predict geomorphological effects in the TRB, and reflects the role of North Atlantic circulation dynamics in central Italian river basins., (© 2021. The Author(s).)

Background and Purpose: A crossover, double-blinded randomized controlled trial to investigate once-daily incremental vestibulo-ocular reflex (VOR) adaptation (IVA) training over 2 years in people with stable and chronic peripheral vestibular hypofunction., Methods: Twenty-one patients with peripheral vestibular hypofunction were randomly assigned to intervention-then-control (n = 12) or control-then-intervention (n = 9) groups. The task consisted of either x1 (control) or IVA training, once daily every day for 15 minutes over 6-months, followed by a 6-month washout, then repeated for arm 2 of the crossover. Primary outcome: vestibulo-ocular reflex gain. Secondary outcomes: compensatory saccades, dynamic visual acuity, static balance, gait, and subjective symptoms. Multiple imputation was used for missing data. Between-group differences were analyzed using a linear mixed model with repeated measures., Results: On average patients trained once daily 4 days per week. IVA training resulted in significantly larger VOR gain increase (active: 20.6% ± 12.08%, P = 0.006; passive: 30.6% ± 25.45%, P = 0.016) compared with x1 training (active: -2.4% ± 12.88%, P = 0.99; passive: -0.6% ± 15.31%, P = 0.68) (P < 0.001). The increased IVA gain did not significantly reduce with approximately 27% persisting over the washout period. x1 training resulted in greater reduction of compensatory saccade latency (P = 0.04) and increase in amplitude (P = 0.02) compared with IVA training. There was no difference between groups in gait and balance measures; however, only the IVA group had improved total Dizziness Handicap Inventory (P = 0.006)., Discussion and Conclusions: Our results suggest IVA improves VOR gain and reduces perception of disability more than conventional x1 training. We suggest at least 4 weeks of once-daily 4 days-per-week IVA training should be part of a comprehensive vestibular rehabilitation program.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A356)., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Academy of Neurologic Physical Therapy, APTA.)

Objective: Previous studies in phobic postural vertigo patients showed characteristic frequency changes in body sway fluctuations, raising the question whether similar spectral changes can be also observed in the recently defined syndrome of persistent postural-perceptual dizziness (PPPD)., Study Design: Cross-sectional prospective study., Setting: Tertiary referral center., Subjects: Sixty-one PPPD patients and 41 healthy controls., Interventions: Static balance was assessed while standing on firm surface with eyes open or closed (conditions 1 and 2) and while standing on foam with eyes open or closed (conditions 3 and 4). Postural sway was analyzed by means of time (sway area and standard deviation) and frequency domain metrics. The latter was based on comparisons of the percentage of energy in each of three frequency bands: low (0-0.5 Hz), middle (0.05-2 Hz), and high frequency (2-20 Hz)., Main Outcome Measure: Stabilometric time and frequency domain parameters., Results: Time domain metrics deteriorated significantly from conditions 1 through condition 4 in patients and controls. Spectral changes, however, were more abundant in PPPD subjects than in controls. Patients showed increased low frequency, but decreased high frequency spectral power in condition 3 as compared to condition 2. Dizziness Handicap Inventory score was positively correlated with middle frequency and negatively correlated with low frequency fluctuations., Conclusions: We conclude that PPPD patients exhibit a time domain sway pattern in different conditions which is grossly similar to that of controls. However, sensory feedback conditions with equal sway area show unique differences in their spectral content in PPPD patients. Moreover, perceived severity of dizziness is associated with greater body oscillations in the middle frequency band., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Hyperventilation-induced downbeat nystagmus (HV-DBN) has been reported in cerebellar disorders and explained by a loss of the inhibitory cerebellar output via a metabolic effect on cerebellar Ca 2+ channels. The aim of this study was to determine the clinical characteristics and underlying pathogenesis of episodic vestibular syndrome (EVS) with HV-DBN. Of 667 patients with EVS, we recruited 22 with HV-DBN and assessed their clinical characteristics, video-oculographic findings, and the results of molecular genetic analyses. The age at symptom onset was 47.5 ± 13.0 years (mean ± SD), and there was a female preponderance (n = 15, 68%). The duration of vertigo/dizziness attacks ranged from minutes to a few days, and 11 patients (50%) fulfilled the diagnostic criteria for vestibular migraine. HV-induced new-onset DBN in 8 patients, while the remaining 14 showed augmentation of spontaneous DBN by HV. The maximum slow-phase velocity of HV-DBN ranged from 2.2 to 11.9°/s, which showed a statistical difference with that of spontaneous DBN (median = 4.95, IQR = 3.68-6.55 vs. median = 1.25, IQR = 0.20-2.15, p < 0.001). HV-DBN was either purely downbeat (n = 11) or accompanied with small horizontal components (n = 11). Other neuro-otologic findings included perverted head-shaking nystagmus (n = 11), central positional nystagmus (n = 7), saccadic pursuit (n = 3), and horizontal gaze-evoked nystagmus (n = 1). Gene expression profiling with a bioinformatics analysis identified 43 upregulated and 49 downregulated differentially expressed genes (DEGs) in patients with EVS and HV-DBN and revealed that the downregulated DEGs were significantly enriched in terms related to the ribosome pathway. Our results suggest that the underlying cerebellar dysfunction would be responsible for paroxysmal attacks of vertigo in patients with EVS and HV-DBN., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

A quality of life questionnaire specific to sarcopenia (SarQoL®) was successfully developed. There is a huge demand for translation and validation in Chinese. The aim of this study was to translate the SarQoL® into Chinese and investigate its psychometric properties. The translation and cross-cultural adaptation process recommended by the developers of the initial questionnaire was followed. A total of 159 participants were investigated. The translation process consists of five steps: (1) two bilinguals independently translate initial English to Chinese; (2) synthesize the two translations into one; (3) backward translations; (4) expert committee review and (5) test of the pre-final version. The validation consists of three parts: (1) validity (discriminative power, construct validity); (2) reliability (internal consistency, test-retest reliability) and (3) floor and ceiling effects. There was no difficulty in translation process. Regarding the validity, good discriminant validity {quality of life for sarcopenic subjects [35.56 (29.73-42.70)] vs. non-sarcopenic ones [73.22 (60.09-82.90)], p < 0.001} and consistent construct validity [high correlations (spearman's r) of SarQoL® with generic Short Form-36 version 2 questionnaire (0.250 to 0.824) and EuroQoL-5-Dimension questionnaire (- 0.114 to - 0.823)] were found in SarQoL®. Regarding reliability, high internal consistency (Cronbach's alpha coefficient was 0.867) and excellent test-retest reliability (intraclass coefficient correlation was 0.997, 95% CI 0.994-0.998) were found. No ceiling/floor effect was reflected. A valid SarQoL® questionnaire is now available for Chinese population. It can provide a better understanding of the sarcopenia disease burden and serve as a therapeutic outcome indicator in research., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Aging is a multidimensional process that may lead to physical, psychological and social changes. This is predominantly due to a decline of sensory functions and their central processing., Material and Methods: Selective literature search in Medline and the Cochrane Library., Results: In addition to specific disorders of the sensory organs, unspecific age-related degenerative processes are responsible for the high prevalence of sensory limitations in older people. This can lead to a significant reduction in the quality of life. Balance impairment, decreasing function of hearing, vision, smell and the somatosensory system are associated with an increased risk of falling and an increased mortality in older people. Furthermore, there is evidence for a link between hearing loss and cognitive decline. In addition to the functional ability of every sense on its own, the integration of multiple sensory perceptions plays an increasing role in age-related sensory limitations., Conclusion: Sensory impairments have to be considered when working with older people. Early detection and an interdisciplinary therapeutic approach can reduce the negative consequences. Multimodal stimulation appears to stimulate brain plasticity which helps to compensate age-related changes., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The burden of cancer continues to increase in society and negatively impacts the lives of numerous patients. Due to the high cost of current treatment strategies, there is a crucial unmet need to develop inexpensive preclinical platforms to accelerate the process of anti-cancer drug discovery to improve outcomes in cancer patients, most especially in female patients. Many current methods employ expensive animal models which not only present ethical concerns but also do not often accurately predict human physiology and the outcomes of anti-cancer drug responsiveness. Conventional treatment approaches for cancer generally include systemic therapy after a surgical procedure. Although this treatment technique is effective, the outcome is not always positive due to various complex factors such as intratumor heterogeneity and confounding factors within the tumor microenvironment (TME). Patients who develop metastatic disease still have poor prognosis. To that end, recent efforts have attempted to use 3D microengineered platforms to enhance the predictive power and efficacy of anti-cancer drug screening, ultimately to develop personalized therapies. Fascinating features of microengineered assays, such as microfluidics, have led to the advancement in the development of the tumor-on-chip technology platforms, which have shown tremendous potential for meaningful and physiologically relevant anti-cancer drug discovery and screening. Three dimensional microscale models provide unprecedented ability to unveil the biological complexities of cancer and shed light into the mechanism of anti-cancer drug resistance in a timely and resource efficient manner. In this review, we discuss recent advances in the development of microengineered tumor models for anti-cancer drug discovery and screening in female-related cancers. We specifically focus on female-related cancers to draw attention to the various approaches being taken to improve the survival rate of women diagnosed with cancers caused by sex disparities. We also briefly discuss other cancer types like colon adenocarcinomas and glioblastoma due to their high rate of occurrence in females, as well as the high likelihood of sex-biased mutations which complicate current treatment strategies for women. We highlight recent advances in the development of 3D microscale platforms including 3D tumor spheroids, microfluidic platforms as well as bioprinted models, and discuss how they have been utilized to address major challenges in the process of drug discovery, such as chemoresistance, intratumor heterogeneity, drug toxicity, etc. We also present the potential of these platform technologies for use in high-throughput drug screening approaches as a replacements of conventional assays. Within each section, we will provide our perspectives on advantages of the discussed platform technologies., (© 2021. Biomedical Engineering Society.)

Aim: Despite the growing interest in sarcopenia in clinical medicine, there is little evidence to support the association between muscle strength and functional prognosis in patients with osteoporotic vertebral fractures. The aim of this study was to evaluate the impact of low handgrip strength (HGS) on functional outcomes in older patients with osteoporotic vertebral fractures., Methods: A prospective cohort study was performed between 2017 and 2019 on consecutive patients with conservatively treated vertebral compression fractures who were newly admitted for post-acute rehabilitation. HGS was measured on admission. Outcomes included the Functional Independence Measure-motor (FIM-motor) score at discharge and length of hospital stay. Multivariate linear regression analyses were utilized to determine whether HGS at baseline was significantly associated with these outcomes after adjustment for potential confounders., Results: Of the 207 patients admitted, 159 patients (mean age 83 years; 78% women) were enrolled in the analysis. The mean (standard deviation: SD) HGS was 15.9 (7.7) kg. Multivariate analysis showed that HGS at admission was independently associated with the FIM-motor score at discharge (β = 0.107, p = 0.006) and length of stay (β = - 0.118, p = 0.030)., Conclusion: Low HGS is commonly found and is associated with reduced functional recovery and prolonged hospital stay in older patients with osteoporotic vertebral fractures. Early detection and interventions for low HGS could help achieve improved outcomes. However, further studies are needed to validate our findings., (© 2021. European Geriatric Medicine Society.)

Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I 2  = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I 2  = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Determination of the water quality monitoring network (WQMN) is a vital stage for surveying ecosystem health. Studies have been done in determining the optimal number and location of sampling points, but seasonality of water quality, especially for heavy metals, has been rarely studied. For the first time, this study proposes a framework to determine the optimal location of sampling points to monitor lead (Pb). This study was conducted for the Karoun River, located in southwestern Iran. First, hydraulic characteristics of the river were simulated by implementing of MIKE11 software as well as water quality(variation of Pb concentration). Nash‑Sutcliffe coefficient were 0.91 and 0.91 for discharge calibration and validation, respectively. Second, 16 potential sampling points were proposed using modified Sanders' approach considering seasonality. For a better accuracy in the WQMN layout and a more efficient site selection of sampling points, a 1-km buffer is stretched along the river for determining non-point source pollution sources and prioritizing candidate points. This leads to considering different land uses in the study area, while GIS software has been employed. Seasonal changes and land use have a significant impact on the location of optimal sampling points. The presented framework can be used to improve water quality and support watershed protection efforts., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: To characterize differences in vestibular testing results among patients presenting with balance-related complaints; to stratify patterns of testing abnormalities by age., Study Design: Retrospective chart review., Setting: Academic Balance Center at a Tertiary Referral Center., Patient Population: All patients who underwent vestibular testing in a 1-year period from 2017 to 2018., Main Outcome Measure: Balance function test results., Results: We reviewed 1,116 patients with age ranging from 11 to 94 years, including 521 patients ≥60 years. Most patients had at least 1 abnormal result, with only 21% of patients ≥60 years and 43% of patients <60 years yielding no test abnormalities (p < 0.001). Among 754 individuals with abnormal testing results, caloric testing did not show any significant difference between age groups. Patients ≥60 years of age were more likely to demonstrate abnormalities on saccadic and horizontal tracking eye movements (p < 0.01; sacc 20.8% vs 6.3%; HT 9.2% vs 4.7%), as well as positional and Dix-Hallpike testing with videonystagmography (p < 0.001; pos 52.3% vs 37.5%, DH 14.4% vs 6.8%). On computerized dynamic posturography, there were significantly more abnormal composite scores in the older group for both sensory organization and motor control testing (p < 0.001; SOT 31.8% vs 8.8%, MCT 7.6% vs 1.8%)., Conclusion: Among patients presenting balance-related complaints, a majority demonstrate at least one abnormality on vestibular testing. While caloric abnormalities occur across the life span, patients ≥60 years of age are more likely to have abnormal results in random saccades, positional, Dix-Hallpike testing, and posturography, with greater effect sizes in tests of central function. While the causes of imbalance and vertigo remain multifactorial, vestibular dysfunction can be considered a major contributor to balance dysfunction in the elderly population and should be thoroughly evaluated., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

The provision of drinking water in metropolises is a challenge that requires programs for continuous monitoring of water quality and processes that impact the land cover of the watershed. In this work, we investigated through multivariate statistical analysis the temporal and spatial trends of several variables, not yet explored in a data series that includes 42 years (1978-2020) of monitoring in the hydrographic basin of the Guarapiranga reservoir, in the São Paulo Metropolitan Region-SPMR (Brazil). This reservoir is the source of drinking water for 3.8 million people and plays a strategic role in the social, environmental, and economic structure at SPMR. Our results point to the continuous degradation of water quality in the reservoir, although with different causes and spatio-temporal aspects. Between the 1970s and 1980s, variables associated with erosion/silting played a more critical role. From the 1990s, the introduction of N and P intensified, and the concentration of thermotolerant coliforms increased. The loss of quality is mainly associated with the progressive advance of urban settlements without planning combined with the inefficient initiatives to control domestic sewage pollution. If there is no rapid and comprehensive intervention, there is a risk that the Guarapiranga reservoir may become unsuitable for drinking water supply and other types of use in the future. This scenario will represent a critical obstacle to regional development and the quality of life of the population.

Purpose: This study aimed to investigate objectively measured physical activity (PA) in institutionalized older adults with mild cognitive impairment (MCI) and to elucidate the influence of autonomic nervous function, salivary cortisol, and PA on cognitive functions based on neurovisceral integration model., Methods: Overall cognitive function was evaluated using the mini-mental state examination (MMSE) and executive function was evaluated using semantic verbal fluency test and clock drawing test. Actigraph for PA, HRV and sAA for autonomous function, and the geriatric depression scale for depression were used. Saliva specimens were collected in the morning for sAA and cortisol., Results: Ninety-eight older adults from four regional geriatric hospitals participated in the study. They took 4,499 steps per day on average. They spent 753.93 minutes and 23.12 minutes on average in sedentary and moderate-to-vigorous activity, respectively. In the multiple regression analysis, lower salivary cortisol level (β = - .33, p = .041) and greater step counts (β = .37, p = .029) significantly improved MMSE score. Greater step count (β = .27, p = .016) also exerted a significant influence on verbal fluency, and greater sAA (β = .35, p = .026) was significantly associated with a better clock drawing test result., Conclusion: Salivary cortisol, sAA and physical activity were significantly associated with cognitive functions. To prevent older adults from developing dementia, strategies are needed to increase their overall PA amount by decreasing sedentary time and to decrease salivary cortisol for cognitive function, and to maintain their sympathetic nervous activity for executive function., Competing Interests: The author declared no conflict of interest., (© 2021 Korean Society of Nursing Science.)

Osteoporosis is nowadays understood as an increased risk of fractures, with bone density measurement by dual-energy X‑ray absorptiometry (DXA) being a useful diagnostic criterion and a potent fracture predictor; however, especially in geriatric patients the result is often falsely negative, so that the diagnosis, indications for treatment and treatment selection should be based on an overall clinical evaluation of the individual situation. Sarcopenia is defined as a geriatric syndrome characterized by a generalized loss of skeletal mass and muscle function. Sarcopenia is associated with an increased likelihood of adverse outcomes including falls, fractures, disability and mortality. Since 2018 it is possible in Germany to encode sarcopenia in the International Statistical Classification of Diseases and Related Health Problems, 10th revision, German modification (ICD-10-GM, M62.50). In the case of a high fracture risk and indications for the presence of sarcopenia, the whole body composition should be assessed by DXA within the framework of the measurement of bone mineral density. In the treatment of osteosarcopenia non-pharmacological measures must be initiated in addition to pharmacological measures. It is particularly important to clarify and if necessary to resolve the cause of falls resulting in fractures as well as to regularly reevaluate the treatment goals.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

Background and Purpose: The Survey of Activities and Fear of Falling in the Elderly (SAFE) was originally developed in English to determine the level of fear of falling and its interactions with activities of daily living. The purpose of this study was to translate and cross-culturally adapt the SAFE instrument into Turkish and investigate its psychometric properties., Participants: One hundred eleven older adults (72 females) with a mean age of 69 years (SD = 7.22; range, 60-87) were included., Methods: For cross-cultural adaptation, 2 bilingual translators used the back-translation procedure. Within a 5- to 7-day period after the first assessment, the participants completed the Turkish version of the SAFE (SAFE-T) to evaluate test-retest reliability. Cronbach's α was used to assess internal consistency. The correlation with the Turkish version of the Falls Efficacy Scale-International (FES-T) was determined to check the validity., Results: The SAFE-T had excellent internal consistency (α = 0.96) and test-retest reliability (intraclass correlation coefficient [ICC2,1] = 0.96 for activity level, ICC2,1 = 0.95 for fear of falling, and ICC2,1 = 0.86 for activity restriction subscales). The SAFE-T activity level and SAFE-T activity restriction subscales were moderately correlated with the FES-I (ρ = -0.51, P < .001; ρ = 0.55, P < .001, respectively). A strong positive correlation was found between the SAFE-T fear of falling subscale and the FES-I (ρ = 0.75, P < .001), indicating good concurrent validity., Conclusions: The results show that the SAFE-T is semantically and linguistically adequate to assess the fear of falling in adults older than 60 years. Excellent internal validity and test-retest reliability of the SAFE-T were defined to evaluate the fear of falling among Turkish speaking older adults., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Academy of Geriatric Physical Therapy, APTA.)

Background: Persistent dizziness without a clear cause is common in older adults. We explored whether an anxiety-driven preoccupation with consciously processing balance may underpin the distorted perceptions of unsteadiness that characterises 'unexplained' dizziness in older adults., Methods: We experimentally induced anxiety about losing one's balance (through a postural threat manipulation) in a cohort of asymptomatic older adults and evaluated associated changes in perceived stability, conscious movement processing and postural control. These outcomes were also assessed when performing a distracting cognitive task designed to prevent anxiety-related conscious movement processing, in addition to during baseline conditions (ground level)., Results: Despite a lack of increase in postural sway amplitude (p = 0.316), participants reported reductions in perceived stability during postural threat compared to baseline (p < 0.001). A multiple linear regression revealed that anxiety-related conscious movement processing independently predicted perceptions of instability during this condition (p = 0.006). These changes were accompanied by alterations in postural control previously associated with functional dizziness, namely high-frequency postural sway and disrupted interaction between open- and closed-loop postural control (ps < 0.014). While the distraction task successfully reduced conscious processing (p = 0.012), leading to greater perceived stability (p = 0.010), further increases in both postural sway frequency (p = 0.002) and dominance of closed-loop control (p = 0.029) were observed., Conclusion: These findings implicate the role of conscious movement processing in the formation of distorted perceptions of unsteadiness, suggesting that such perceptions may be modifiable by reducing an over-reliance on conscious processes to regulate balance.

Background: Vertigo is a well-known presenting complaint common in the main care offices as well as departments. It is also regarded as a symptom of vestibular dysfunction and has been expressed as a feeling of motion, specifically rotational motion. As patients grow older, vertigo also becomes a commonly presenting complaint. The current study will carry out a widespread systematic review to estimate clinical therapeutic effects of gastrodin in combination with betahistine on vertigo., Methods: We will systematically search different databases, including PubMed, EMBASE, Web of Science, the Cochrane Library, Chinese BioMedical Literature Database (CBM), China National Knowledge Infrastructure Database (CNKI), and WanFang to collect the randomised controlled studies that evaluate the efficiency of gastrodin and betahistine in treating patients with vertigo from their inception to November 2020. However, only studies in English or Chinese will be included. Two authors will independently perform selection, data extraction, and assessment of risk of bias for the included papers. Accordingly, any disagreements between the independent authors will be addressed via discussion or by consulting a third author when needful. Additionally, we will use RevMan 5.3 software to perform the data synthesis., Results: The efficiency of gastrodin and betahistine in treating patients with vertigo will be systematically evaluated., Conclusions: The current study aims to stipulate more consistent substantiation to explore whether gastrodin combined with betahistine is more effective for the treatment of vertigo., Registration Number: DOI 10.17605/OSF.IO/HQTZA (https://osf.io/hqtza/)., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rural headwater catchments are important to describe the connectivity of pollution sources to water bodies. Strategies to optimize water quality monitoring networks, as parameter definition, sampling, and statistical approach, have been widely discussed. The objectives of this study were to describe the spatial and temporal dynamics (intra- and inter-events) of water quality and to establish its implications for environmental monitoring programs. The monitoring was carried out in a rural headwater catchment (1.2 km 2 ) with shallow soils, high slopes, and intense agricultural activity in Southern Brazil. To better describe the impact of agriculture on water resources, the monitoring strategy was based on definition of the best set of parameters and different sampling frequency to incorporate intra- and inter-event variability and statistical analysis approach. We also analyzed parameters in different sub-basins with physiographic traits. Three hydrological compartments were analyzed: surface flow, groundwater, and base flow. Physico-chemical parameters, the concentration of elements associated with agricultural activity, and biological parameters were evaluated. Total phosphorus and turbidity were the parameters most affected by agricultural activity. They reflected on the inter- and intra-events, the impacts of soil and water degradation by agricultural activity, and the precarious rural sanitation conditions. Spatiotemporal variability of the parameters characterizes the different mechanisms for transferring pollutants from diffuse sources to water bodies. Spatial and temporal patterns in water quality changes were used to discuss environmental monitoring strategies, such as parameter and sampling frequency definition, to improve soil and water conservation programs at the catchment scale.

Perceived social support can help immigrant youth to deal with developmental acculturation: the simultaneous resolution of developmental and acculturative tasks. This person-oriented three-wave comparative study investigated perceived social support trajectories in two immigrant and one non-immigrant group. We investigated whether similar social support trajectory classes can be found across groups, whether developmental and/or acculturation-related processes predict class membership, and whether social support trajectory classes associate with changes in self-efficacy. The sample comprised 1326 ethnic German immigrant and 830 non-immigrant adolescents in Germany, and 1593 Russian Jewish adolescents in Israel (N = 3749; M age = 15.45; SD = 2.01; 50% female). Results revealed two social support trajectory classes across all and within each group: a stable well-supported class and a low but increasingly-supported class. Respective to the increasingly-supported class, membership in the well-supported class was associated with commonality in developmental predictors (female gender, high involvement with family and peers) in all groups and specificity in acculturation-related predictors (higher heritage and host culture orientation) in immigrant groups. Patterns of self-efficacy over time matched social support trajectories of both classes in all groups. Findings indicate that stakeholders looking to support immigrant adolescents should be aware of the nuanced coaction of development and migration., (© 2021 The Authors. New Directions for Child and Adolescent Development published by Wiley Periodicals LLC.)

Objectives/hypothesis: This study aimed to evaluate the prevalence of peripheral vestibular disorders in an Asian population of predominantly Han Chinese ethnicity., Study Design: Cross-sectional study., Methods: Patients with a peripheral vertigo disorder were identified from the Taiwan Health Insurance Research Database, a database of all medical claims of a randomly selected, population-representative sample of 2 million enrollees of Taiwan's National Health Insurance system covering over 99% of Taiwan's citizens. In 2016, 59,986 patients received a diagnosis of peripheral vestibular disorders in Taiwan. We calculated the population-wide prevalence rates of peripheral vestibular disorders in 2016 by sex and age group (20 to 24, 25 to 29, 30 to 34, 35 to 39, 40 to 44, 45 to 49, 50 to 54, 55 to 59, 60 to 64, 65 to 69, and ≥ 70 years) stratified into five urbanization levels., Results: The prevalence rate of peripheral vestibular disorders was 2,833.4 per 100,000 population during the year. Prevalence of Meniere's disease was 70.4 per 100,000, benign paroxysmal positional vertigo, 446.4, vestibular neuritis 307.2, and other or unspecified peripheral vestibular dizziness, 2,009.5 per 100,000. Prevalence rates steadily increased with age for every type of peripheral vestibular disorder, and were higher among females compared to males. The female-to-male gender ratios were 1.84, 1.89, and 1.93 for Meniere's disease, vestibular neuritis, and other peripheral vestibular dizziness, respectively. Counties with the lowest urbanization level had the highest prevalence rates of all types of peripheral vestibular disorders except vestibular neuritis., Conclusions: Results showed that peripheral vestibular disorders are common in Taiwan, increase with age, are predominantly female, and show higher prevalence in rural areas., Level of Evidence: 2b Laryngoscope, 131:639-643, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion., Setting: Community., Participants: Family physicians in community practice (n = 21 at 5 clinics)., Design: Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits., Main Measures: The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements., Results: Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change., Conclusions: Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives/hypothesis: This study aimed to assess the association of prior cervical spondylosis (CS) with peripheral vertigo., Study Design: Case-control study., Methods: Data were retrieved from the Taiwan Longitudinal Health Insurance Database. A total of 2,570 patients who were newly diagnosed with peripheral vertigo were identified. We compared them with a 3:1 ratio of propensity score-matched patients, 7,710 comparison patients from the same dataset. We performed multivariate logistic regressions to estimate the odds ratio for prior CS occurrence among peripheral vertigo patients versus controls., Results: Of 10,280 sample patients, 1,739 (16.92%) patients had CS prior to the index date. A significant difference in prior CS between peripheral vertigo patients and controls (19.49% vs. 16.06%, P < .001) was observed. Logistic regression analysis shows that the odds of prior CS was 1.285 for peripheral vertigo patients versus controls (95% confidence interval [CI]: 1.143-1.446) after adjusting for age, sex, urbanization level, monthly income, geographic region, hyperlipidemia, diabetes, coronary heart disease, hypertension, and asthma. Prior CS with myelopathy was not associated with peripheral vertigo. Stratified analysis by age showed that the odds of CS were highest among patients with peripheral vertigo in the 45- to 64-year-old age group (1.442, 95% CI: 1.215-1.712)., Conclusions: CS is associated with subsequent peripheral vertigo in the Taiwan population, with higher risk among those aged 45 to 64 years., Level of Evidence: 2b Laryngoscope, 131:E625-E630, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Implementation of evidence-based practices often requires tailoring implementation strategies to local contextual factors, including available resources, expertise, and cultural norms. Using an exemplar case, we describe how health systems engineering methods can be used to understand system-level variation that must be accounted for prior to broad implementation., Methods: Within the context of a single-center quality improvement activity, a multi-disciplinary stakeholder team used health systems engineering methods to describe how pre-endoscopy antithrombotic management was executed, and implemented a redesigned process to improve clinical care. The research team then conducted multiple stakeholder focus groups at four different health-care systems to describe and compare current processes for pre-endoscopy antithrombotic medication management. Detailed work flow maps for each health-care system were developed, analyzed, and integrated to develop an overarching current work flow map, identify key process steps, and describe areas of process variation., Results: Five key process steps were identified across the four health systems: (1) place an endoscopy order, (2) screen for antithrombotic use, (3) coordinate medication management, (4) instruct the patient, and (5) confirm appropriate medication management before procedure. Across health systems, we found a high degree of variation in each step (e.g., who performed, use of technology, systematic vs. ad hoc process). This variation was influenced by two key system-level contextual factors: (1) degree of health system integration and (2) role and training level of available staff. These key steps, areas of variation, and contextual factors were integrated into an assessment tool designed to facilitate tailoring of a future implementation and dissemination strategy., Conclusions: Tools from health systems engineering can be used to identify key work flow process steps, variations in how those steps are executed, and influential contextual factors. This process and the associated assessment tool may facilitate broader implementation tailoring.

Background and Purpose: Acute vestibular symptoms have a profound impact on patients' well-being. In this study, health-related quality of life (HRQoL) and functional impairment were investigated prospectively in patients with different peripheral and central vestibular disorders during the acute symptomatic stage to decipher the most relevant underlying factors., Methods: In all, 175 patients with acute vestibular disorders were categorized as central vestibular (CV, n = 40), peripheral vestibular (PV, n = 68) and episodic vestibular disorders (EV, n = 67). All patients completed scores to quantify generic HRQoL (European Quality of Life Score Five Dimensions Five Levels, EQ-5D-5L) and disease-specific HRQoL (Dizziness Handicap Inventory, DHI). Vestibular-ocular motor signs were assessed by video-oculography, vestibular-spinal control by posturography and verticality perception by measurement of subjective visual vertical., Results: Patients with PV had a poorer HRQoL compared to patients with CV and EV (EQ-5D-5L/DHI: PV, 0.53 ± 0.31/56.1 ± 19.7; CV, 0.66 ± 0.28/43.3 ± 24.0; EV, 0.75 ± 0.24/46.7 ± 21.4). After adjusting for age, gender, cardiovascular risk factors and non-vestibular brainstem/cerebellar dysfunction patients with PV persisted to have poorer generic and disease-specific HRQoL (EQ-5D-5L -0.17, DHI +11.2) than patients with CV. Horizontal spontaneous nystagmus was a highly relevant factor for subgroup differences in EQ-5D-5L and DHI, whilst vertical spontaneous nystagmus, subjective visual vertical and sway path were not. EQ-5D-5L decreased significantly with more intense horizontal subjective visual vertical in CV (rho = -0.57) and PV (rho = -0.5) but not EV (rho = -0.13)., Conclusions: Patients with PV have the highest functional impairment of all patients with acute vestibular disorders. Vestibular-ocular motor disturbance in the yaw plane has more impact than vestibular-spinal or vestibular-perceptive asymmetry in the roll and pitch plane, suggesting that horizontal visual stability is the most critical for HRQoL., (© 2020 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Objective: Identify clinical screening tests to proficiently screen for patients with vestibular disorders., Study Design: Retrospective case-control study., Setting: Tertiary referral center., Patients: 318 healthy individuals and 331 subjects with vestibular disorders., Interventions: All subjects performed Romberg and Jendrassic maneuver with eyes closed (ROMJec), standing on foam with eyes open (SOFeo) and eyes closed (SOFec), Tandem Romberg with eyes open (TReo) and eyes closed (TRec), single leg stance with eyes open (SLSeo) and eyes closed (SLSec), Tandem gait (TG) and Timed Up and Go (TUG)., Main Outcome Measures: Significant differences in performance on the balance tests., Results: For the age-group <40 years, TUG >6 seconds (OR 102.4; p <0.0001) and SLSec <30 seconds (OR 48.0; p <0.0001) proved to be the most predictive combination of testing (AUC 0.9; LR+ 15.8; LR- 0.2), with a positive predictive value (PPV) of 88.4%. For the age-group 40-60, TUG >7 seconds (OR 4.0; p = 0.0107) and TRec <30 seconds (OR 63.1; p < 0.0001) was the most predictive combination of tests (AUC 0.9 LR+ 6.0; LR- 0.1), with a PPV of 93.8%. For the age-group >60 the combination of TUG >8 seconds (OR 17.4; p < 0.0001) and SOFec <30 seconds (OR 10.4; p < 0.0001) was the most predictive (AUC 0.9 LR+ 6.3; LR- 0.2), with a PPV of 84.8%., Conclusions: Combinations of clinical tests are proposed to promptly screen for vestibular disorders in specific age groups. To interpret the results for the individual patient, the physician must take the history and the general examination into consideration.

Purpose of Review: Providing an update on the pathophysiology, cause, diagnosis and treatment of cerebellar ataxias. This is a group of sporadic or inherited disorders with heterogeneous clinical presentation and notorious impact on activities of daily life in many cases. Patients may exhibit a pure cerebellar phenotype or various combinations of cerebellar deficits and extracerebellar deficits affecting the central/peripheral nervous system. Relevant animal models have paved the way for rationale therapies of numerous disorders affecting the cerebellum., Recent Findings: Clinically, the cerebellar syndrome is now divided into a cerebellar motor syndrome, vestibulocerebellar syndrome and cerebellar cognitive affective syndrome with a novel clinical scale. This subdivision on three cornerstones is supported by anatomical findings and neuroimaging. It is now established that the basal ganglia and cerebellum, two major subcortical nodes, are linked by disynaptic pathways ensuring bidirectional communication. Inherited ataxias include autosomal recessive cerebellar ataxias (ARCAs), autosomal dominant spinocerebellar ataxias and episodic ataxias and X-linked ataxias. In addition to the Movement Disorders Society genetic classification of ARCAs, the classification of ARCAs by the Society for Research on the Cerebellum and Ataxias represents major progress for this complex subgroup of cerebellar ataxias. The advent of next-generation sequencing has broadened the spectrum of cerebellar ataxias., Summary: Cerebellar ataxias require a multidisciplinary approach for diagnosis and management. The demonstration of anatomical relationships between the cerebellum and basal ganglia impacts on the understanding of the cerebello-basal ganglia-thalamo-cortical system. Novel therapies targeting deleterious pathways, such as therapies acting on RNA, are under development.

Current scar surveys have included many questions to evaluate the physical characteristics of scars, with some expanding to include physical implications and patient opinions. This review provides an analysis of frequently used scar assessment methods to date and highlights potential areas for improvement. We build the case that a new assessment tool is necessary, specifically one that centers on psychosocial consequences of scars that influence patient decision making for treatment, allowing physicians to individualize treatment conversations with patients. We postulate that survey techniques used in consumer product marketing, such as choice-based conjoint analysis, may be effective in determining the factors strongly influencing patient decision making and spending in scar treatment; therefore, more research in this area is warranted. By incorporating these psychosocial and economic considerations driving scar treatment decisions, future scar assessment tools may accomplish much more than characterizing/documenting the clinical aspects of scars. Rather, these patient-centered, holistic tools may be implemented by plastic surgeons and other clinicians specifically to provide patients with personalized treatment options that maximize long-term patient satisfaction.

Assessment of the quality of freshwater bodies is essential to determine the impact of human activities on water resources. The water quality status is estimated by comparing indicators with standard thresholds. Indicators are usually statistical criteria that are calculated on discrete measurements of water quality variables. If the time step of the measured time series is not sufficient to fully capture the variable's variability, the deduced indicator may not reflect the system's functioning. The goal of the present work is to assess, through a hydro-biogeochemical modeling approach, the optimal sampling frequency for an accurate estimation of 6 water quality indicators defined by the European Water Framework Directive (WFD) in a large human-impacted river, which receives large urban effluents (the Seine River across the Paris urban area). The optimal frequency depends on the sampling location and on the monitored variable. For fast varying compounds that originate from urban effluents, such as PO[Formula: see text], NH[Formula: see text] and NO[Formula: see text], a sampling time step of one week or less is necessary. To be able to reflect the highly transient character of bloom events, chl a concentrations also require a short monitoring time step. On the contrary, for variables that exert high seasonal variability, as NO[Formula: see text] and O 2 , monthly sampling can be sufficient for an accurate estimation of WFD indicators in locations far enough from major effluents. Integrative water quality variables, such as O 2 , can be highly sensitive to hydrological conditions. It would therefore be relevant to assess the quality of water bodies at a seasonal scale rather than at annual or pluri-annual scales. This study points out the possibility to develop smarter monitoring systems by coupling both time adaptative automated monitoring networks and modeling tools used as spatio-temporal interpolators.