| Objective:Episodic vestibular syndrome(EVS)is common clinical vertigo,in which some patients have fewer times of vertigo and have little impact on quality of life or other after the symptoms disappear.However,the recurrent attacks of vertigo in other patients have a significant impact on work and life.However,the current diagnosis rate is low,and treatment means are lacking.Reactive EVS has become one of the main vertigo problems,and a large number of cases are received every day in outpatient and emergency departments,and the number of patients increases rapidly year by year.It is vital to identify these two patients with different outcomes in time and carry out different intervention measures.Since Barany Society Meeting in 2016,the international and domestic diagnosis and treatment ideas have gradually shifted from the identification research of a single vertigo disease to classification based on clinical features,calling on researchers not to focus on a single vestibular primary disease,but to study the overall role of ICVD from the four correlation levels.This study aims to collect critical clinical data of vertigo,such as chief complaint,concomitant symptoms,underlying diseases,routine examinations,etc.Therefore,the first part of the study was the first to establish a specialized clinical database for EVS,covering102 variables of as comprehensive history and examination as possible,for further clinical feature analysis.The second part,based on the established large-scale clinical database,take the repeatedly,with bad control effect ones,the refractory paroxysmal vestibular syndrome to compare with non-refractory patients,found out the particular clinical regularity,summary analysis to find out the unique clinical features of refractory vertigo,combined with the essential related clinical data.For example,the specific symptoms of vertigo,life inducement,complications and sociological characteristics of vertigo that can not be accurately collected and wholly presented in the routine outpatient medical database,so as to establish the prediction model of recurrent risk of episodic vestibular syndrome,to realize the clinical guidance for the stratified diagnosis and treatment of the episodic vestibular syndrome.Because the second part failed to include video head impulse test(vHIT)and vestibular evoked myogenic potentials(VEMP),the third part aims to suplenish the follow-up study,to explore the two means of clinical examination,compared with the classic video nystagmus graph(VNG)for testing the vestibular function,in order to understand their recognition ability of refractory EVS.The fourth part is about the most definitive diagnosis of EVS,benign paroxysmal positional vertigo(BPPV).Because the diagnosis of BPPV is much easier,generally do not need to rely on detailed medical history,and the complex vestibular function examination to diagnosis,in order to avoid the waste of medical resources,so the design of the second part of study excluded patients with BPPV,therefore this part discusses intractable BPPV alone and risk factors for recurrence.Through these four parts,refractory episodic vestibular syndrome compared with the patients with non-refractory ones can be applied to form a clinical prediction model,explore the diagnostic test of its examination,in order to identify the intractable episodic vestibular syndrome earlier,reduce the excessive diagnosis and treatment for patients with non-resistant EVS,early detection for patients with refractory recurrent,so that doctors can provide early intervention,reduce the proportion of the forced damaging surgery to patients.Materials and Methods:1.Establishment of the registration database of patients with episodic vestibular syndrome: a database developing team was established for the study,with dedicated personnel and special responsibilities for research and development;In the structured,standard medical record report form,the medical history registration form included49 detailed medical history variables,including detailed symptoms,onset time,onset frequency,aggravating and mitigating factors,negative symptoms,concomitant symptoms,past history,and family history.The vestibular function examination registration form included 53 detailed examination variables,such as saccade test,smooth pursuit test,optokinetic test,gaze test,spontaneous nystagmus,positional nystagmus,and biothermal test.To advance the development of variable dictionary,the forms and modified in advance,a collection of January 2017-December 2019,three years,in outpatient of hospital,with episodic vestibular syndrome patients,to register,fill out the EVS case report form and VNG examination,according to rule out standard screening into the database.At the same time,completed the compilation of the database operation manual and carried out specific operation methods book and personnel training to ensure the consistency of results.Data entry is double reading and double-entry with Epi Data electronic form.Formal error correction is used in the input,logical error checking and double-entry error checking are used after the completion of the input,and then manual data cleaning and random manual spotchecking are carried out based on checking the report.Finally,a professional clinical database was established for the episodic vestibular syndrome,and the general characteristics of patients were preliminarily analyzed.2.Construction of recurrence risk model of EVS: Outcome index was refractory recurrence after-treatment of the episodic vestibular syndrome.The study protocol was designed as a case-control study.Firstly,the patients with non-benign paroxysmal positional vertigo in the database were simply randomized and divided into 70%modeling population and 30% verification population.Patients were grouped according to whether they were stubborn or not.A single-factor chi-square test was conducted between two groups of patients in the modeling population.For variables with statistical significance(P < 0.05),Lasso regression was used to eliminate the correlation between variables and determine the number of variables entering the model.Multivariate Logistic regression was used to calculate the risk of each factor.Then,an individualized relapse risk prediction model was established by using the histogram.Finally,the ROC curve,C index quantization model,and prediction model calibration curve are used to verify and evaluate the modeling population and verification population respectively.3.Comparison of three methods of vestibular function examination: a diagnostic test was designed to examine the diagnostic effect of two new tests,video head pulse test and vestibular evoked myogenic potential,in peripheral refractory EVS,compared with classical video nystagmus electrogram.The patients with the refractory episodic vestibular syndrome who were admitted to our hospital from January 2020 to April 2021 were reviewed.The refractory patients who underwent three kinds of examinations simultaneously were screened,and the results of the two new examinations were extracted and compared with the results of VNG.The statistical method used the ROC curve analysis of the classification data first,then used the consistency statistic Kappa coefficient to carry out the consistency test.4.Analysis of recurrence risk factors of BPPV: This study was designed as a prospective case-control study.BPPV patients in the database were divided into two groups: the intractable group and the control group according to the same method and were followed up regularly until December 2020.The frequency/percentage was used for the statistical description of the classification variables.The Chi-square test and t test was used for comparison between groups.Age was used for statistical description by mean ± standard deviation.Results:1.The database development team of this study designed and improved the detailed EVS case report form and prepared a detailed variable dictionary and a manual for special personnel operation.Each data contained 49 detailed history variables and 53 detailed examination variables,and finally collected more than250,000 variable data from 2,194 patients.An extensive database of the episodic vestibular syndrome has been established and used successfully.2.Univariate analysis and Lasso regression were carried out on 1710 non-BPPV EVS patients’ data using the database,and nine variables were screened for multivariate Logistic regression analysis,and a risk prediction model was constructed.It was found that visual rotation(OR=4.38,P<0.0001),floating sense(OR=3.47,P<0.0001),sense of rotation(OR=2.25,P <0.0001),neck and shoulder pain(OR=1.84,P<0.0001),premonition before attack(OR=1.59,P=0.0037),hyperlipidemia(OR=1.53,P =0.02),migraine(OR=1.40,P =0.04)and family history(OR=1.35,P=0.07)were independent risk factors for refractory EVS,and the risk of refractory EVS increased by about 338%,247%,125%,84%,59%,53%,40%,35%,respectively.On the contrary,the sense of imbalance(including shaking,leaning,and tipping)was a protective factor for refractory EVS(OR=0.47,P<0.0001),and patients with symptoms of imbalance had a reduced risk of refractory EVS by about 53%.3.On this basis,the nomogram is drawn,and the model is visually displayed so as to display the model results more intuitively and facilitate clinical practice and application.In addition,the model-set nomograms were used for internal verification,and the C index was all greater than 0.8.In addition,the calibration chart also showed that the predicted incidence was in good agreement with the actual observation.4.The general characteristics of patients with episodic vestibular syndrome were summarized: the ratio of male to female was 1:1.6,with slightly more females;The mean age was 48.83,and the median age was 49.The mean age of the first onset was44.06,and the median age of the first onset was 44.The patient population conforms to the normal distribution,and the patients in the 40-50 years old group are the most.The more attacks,the fewer patients;The number of patients with recurrence within one month to 2 years was the largest,accounting for more than 40%,and then gradually decreased,and more than 80% of patients had recurrence within ten years.5.The detection rates of VNG,vHIT,and VEMP were between 50-70%,and the AUC values of vHIT,VEMP,and VNG were 0.535 and 0.627,respectively.The Kappa values in the consistency test were 0.061 and 0.258,respectively,indicating that the consistency between these three methods was poor,and different vestibular problems might be detected.6.Follow-up of 484 patients with BPPV in the database showed that there were440 patients in control BPPV group and 44 patients in the refractory BPPV group.The proportion of undetected nystagmus and central location nystagmus in the refractory BPPV group was significantly higher(P <0.05),which was statistically significant.Among all possible risk factors,the recurrence of BPPV was only associated with obstinacy/control grouping(P <0.05)and not with gender,gender,metabolic disease,past history,family history,etc.(P > 0.05).Conclusion:1.In this study,we designed and probably for the first time successfully developed a high-quality database for the registration of episodic vestibular syndrome including a large comprehensive registration form,which is expected to make up for the important clinical information about episodic vestibular syndrome and provide a convenient,efficient,and reliable informational tool for the development of clinical topics in the future;2,Developed maybe for the first time based on the clinical history of high accuracy,simple,actionable clinical prediction model for intractable vertigo in hospitals and doctors identify patients’ outcomes,shunt attack episodic vestibular syndrome patients correctly,make a further inspection and diagnosis of difficult patients as soon as possible,to achieve efficient and referral,it is of great importance and realistic significance to save social and medical resources.3,By collecting EVS patients,we establish a professional database,statistics set out as general symptoms of patients with episodic vestibular syndrome characteristics,and select the EVS predictor of recurrence,which rotate,floating,own rotating,neck shoulder pain,hyperlipidemia,migraine,and family history are independent risk factors for recurrence of EVS.Patients with these symptoms have an increased risk of recurrence of EVS;The sense of unbalance(including shaking,leaning,and tipping)was a protective factor for recurrence of EVS,and patients with unbalance symptoms reduced the risk of recurrence of EVS by about half.4.The detection rates of VNG,vHIT,and VEMP were not as high as previously reported in single diseases,and they were not particularly satisfactory,suggesting that intractable peripheral episodic vestibular dysfunction may be caused by entirely different etiology.vHIT test and VEMP test can compensate but cannot replace VNG.In clinical work,the evaluation of peripheral vestibule function needs to be combined with various examination techniques for comprehensive evaluation.5.The recurrence rate of BPPV is not very high,and it may be more important to do a good job of exclusion diagnosis;Refractory BPPV patients have a small proportion of general diseases,semicircular canal paresis and so on.The recurrence rate was not correlated with age,gender,metabolic diseases,etc.,possibly because the follow-up time in this study was longer. |
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