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We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.

OBJECTIVES: To examine post-traumatic stress, depression, anxiety, and well-being in older adults under quarantine. METHODS: A systematic review of CINAHL, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science from 2000 to 2020 was conducted. Keywords included coronavirus, epidemic, quarantine, stress, mental health, and similar terms. Included studies enrolled participants under quarantine, quantitatively measured mental health or well-being, and characterized outcomes by age. RESULTS: Of 894 initial results, 20 studies met the criteria and were included. Studies comprise 106,553 participants from eight countries, ages 6–100, two epidemics (COVID-19, SARS), and 27 assessment tools. One study found greater distress in older adults relative to younger adults, one found no significant differences, and 18 found lower negative outcomes in older participants in at least one metric. CONCLUSIONS: Older adults in this review generally have lower stress and less negative emotions under quarantine than younger adults. It is unknown how this compares to pre-pandemic mea¬sures. More representative and longitudinal studies are needed to measure the impact of quarantine on the mental health of older adults. CLINICAL IMPLICATIONS: As existing scales may not capture the full extent of pandemic psychological effects on older adults, clinicians must vigilantly monitor older adults’ mental health.

Background Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. Methods We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. Results A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). Conclusions We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

BACKGROUND The objective was to systematically evaluate the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) for transient global amnesia (TGA) across various time frames compared to the reference-standard clinical criteria. METHODS All indexed publications related to TGA and MRI through June 2020 were retrieved by a medical librarian. Two independent reviewers identified original research studies of adults with a clinical diagnosis of TGA using Caplan and Hodges and Warlow criteria (reference standard) who were evaluated with DW-MRI. Pooled estimates and its 95% confidence intervals (CI) for the proportion of acute TGA patients with positive DW-MRI (i.e., sensitivity) were obtained using random-effects meta-analysis for various time frames. Quality assessment was performed using the revised Quality of Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS After screening 665 reports, we identified 81 potentially relevant studies. Twenty-three studies representing 1688 patients met eligibility criteria, but not all studies had data available for meta-analysis. The pooled sensitivity (also described as positivity rate) of DW-MRI was 15.6% (95% CI = 2.6%-35.0%) between 0 and 12 h from symptom onset, 23.1% (95% CI = 6.1%-45.7%) at 0-24 h, 72.8% (95% CI = 40.8%-96.3) at 12-24 h, 68.8% (95% CI = 44.8%-88.8%) at 24-36 h, 72.4% (95% CI = 59.8%-83.5%) at 36-48 h, 82.8% (95% CI = 54.7%-99.6%) at 48-60 h, 66.9% (95% CI = 47.5%-83.9%) at 60-72 h, and 72.0% (95% CI = 30.1%-100.0%) at 72-96 h. There was significant concern for risk of bias in the QUADAS-2 domains of patient selection and index test, yielding a low level of certainty in the pooled estimates. CONCLUSION DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low-yield test.

Background Statins up-regulate angiotensin-converting enzyme 2, the receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), while also exhibiting pleiotropic antiviral, antithrombotic, and anti-inflammatory properties. Uncertainties exist about their effect on the course of SARS-CoV-2 infection. We sought to systematically review the literature and perform a meta-analysis to examine the association between prior statin use and outcomes of patients with coronavirus disease 2019 (COVID-19). Methods We searched Ovid Medline, Web of Science, Scopus, and the preprint server medRxiv from inception to December 2020. We assessed the quality of eligible studies with the Newcastle-Ottawa quality scale. We pooled adjusted relative risk (aRRs) of the association between prior statin use and outcomes of patients with COVID-19 using the DerSimonian-Laird random-effects model and assessed heterogeneity using the I2 index. Results Overall, 19 (16 cohorts and 3 case-control) studies were eligible, with a total of 395 513 patients. Sixteen of 19 studies had low or moderate risk of bias. Among 109 080 patients enrolled in 13 separate studies, prior statin use was associated with a lower risk of mortality (pooled aRR, 0.65 [95% confidence interval {CI}, .56–.77], I2 = 84.1%) and a reduced risk of severe COVID-19 was also observed in 48 110 patients enrolled in 9 studies (pooled aRR, 0.73 [95% CI, .57–.94], I2 = 82.8%), with no evidence of publication bias. Conclusions Cumulative evidence suggests that prior statin use is associated with lower risks of mortality or severe disease in patients with COVID-19. These data support the continued use of statins medications in patients with an indication for lipid-lowering therapy during the COVID-19 pandemic., Preexisting use of statins in patients with coronavirus disease 2019 (COVID-19) is associated with reduced risk of mortality and severe COVID-19. Statins should continue to be utilized in patients with indications.

Objectives:To examine post-traumatic stress, depression, anxiety, and well-being in older adults under quarantine in the context of epidemics.Methods:A systematic review of CINAHL, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science databases from 2000-2020 was conducted. Keywords included coronavirus, epidemic, quarantine, stress, mental health, and similar terms. Included studies enrolled participants under quarantine, quantitatively measured of mental health or psychological well-being, and characterized outcomes by age.Results:Of 894 initial results, 20 studies met criteria and were included in the analysis. Studies comprise a total of 106,553 participants from eight countries, age range 6-100, involved two epidemics (COVID- 19, SARS), and used 27 tools used to assess psychological responses to quarantine. The majority (70%) of the studies utilized recruited participants through online surveys, utilizing open web and snowball recruitment. Of the 20 studies, one found greater distress in older adults relative to younger adults on a COVID-19 distress scale, one study found no significant differences, and 18 studies found lower negative outcomes in older participants in at least one metric.Conclusions:Older adults in this review generally have lower stress and less negative emotions under quarantine than younger adults. It is unknown how this compares to the pre-pandemic state. More representative and longitudinal studies are needed to better measure the impact of quarantine on the mental health of older adults.Clinical Implications:As existing scales may not capture the full extent of pandemic’s psychological effects on older adults, clinicians must be vigilant in monitoring older adults’ mental health in quarantine.

BACKGROUND AND OBJECTIVES Dorsal root ganglion stimulation (DRGS) is a newer form of neuromodulation that targets the dorsal root ganglion. DRGS has superior efficacy in complex regional pain syndrome compared to spinal cord stimulation (SCS) and may have efficacy in other forms of chronic pain. While decades of safety data are available for SCS, there is less available safety information for DRGS. The objectives of this systematic review and pooled analysis of incidence are to determine the overall incidence of DRGS infections, incidence at each stage (trial vs. implant vs. revision), infection characteristics, and outcomes. MATERIALS AND METHODS A comprehensive search of databases from January 1980 to January 2021 was conducted. RESULTS Ten studies met inclusion criteria. Eight studies reported patients with trial data (n = 291), ten studies reported patients with implant data (n = 250), and seven studies reported data with revisions (n = 26). The pooled incidence of trial infections was 1.03% (95% CI 0.35-2.99%), implant infections was 4.80% (95% CI 2.77-8.20%), revision infections was 3.85% (95% CI 0.20-21.59%), and overall infections was 2.82% (95% CI 1.62-4.54%). There was a statistically significant difference in infection rates between the trial, implant, and revision stages, X2 (2, N = 567) = 8.9839, p = 0.01. CONCLUSIONS This is the first systematic review and pooled analysis that followed PRISMA guidelines to report infectious complications of DRGS by stage (trial vs. implant vs. revision). DRGS trial appears to be low risk for infection but that risk is significantly increased with DRGS implant. Our findings highlight the need for further study of infectious complications, their risks, and optimal prophylaxis.

Many meta‐analyses have been published about the efficacy of hydroxychloroquine (HCQ) in coronavirus disease 2019 (COVID‐19). Most of them included observational studies, and few have assessed HCQ as a prophylaxis or evaluated its safety profile. We searched multiple databases and preprint servers for randomized controlled trials (RCTs) that assessed HCQ for the treatment or prevention of COVID‐19. We summarized the effect of HCQ on mortality, viral clearance, and other clinical outcomes. Out of 768 papers screened, 21 RCTs with a total of 14,138 patients were included. A total of 9 inpatient and 3 outpatient RCTs assessed mortality in 8596 patients with a pooled risk difference of 0.01 (95% confidence interval [CI] 0.00–0.03, I2 = 1%, p = 0.07). Six studies assessed viral clearance at 7 days with a pooled risk ratio (RR) of 1.11 (95% CI 0.86–1.42, I2 = 61%, p = 0.44) and 5 studies at 14 days with a pooled RR of 0.96 (95% CI 0.89–1.04, I2 = 0%, p = 0.34). Several trials showed no significant effect of HCQ on other clinical outcomes and. Five prevention RCTs with 5012 patients found no effect of HCQ on the risk of acquiring COVID‐19. Thirteen trials showed that HCQ was associated with increased risk of adverse events. We observed, with high level of certainty of evidence, that HCQ is not effective in reducing mortality in patients with COVID‐19. Lower certainty evidence also suggests that HCQ neither improves viral clearance and other clinical outcomes, nor prevents COVID‐19 infection in patients with high‐risk exposure. HCQ is associated with an increased rate of adverse events.

IntroductionDelirium is commonly missed in older adults presenting to the emergency department (ED). Although current recommendations for active screening of delirium in the ED, this might not be feasible or practical. Identifying patients at high risk for prevalent and incident delirium in the ED will help to improve the screening process and to build interventions. There is currently scattered synthesis of evidence on risk factors associated with delirium in the ED. To address this gap, we are conducting a systematic review to describe the risk factors (patient vulnerability factors and precipitating factors) for delirium in the ED.Methods and analysisA literature search was performed from inception to March 2020 in Ovid EBM Reviews, Ovid EMBASE, Ovid MEDLINE, Scopus and Web of Science. We will include original research studies that report a quantitative relationship between at least one risk factor and delirium in the ED setting. Two investigators will use eligibility criteria from this protocol to independently screen titles and abstracts, and select studies based on full-text review of potentially eligible studies. After arriving at a final set of included studies, two investigators will extract data using a standardised data collection form. If appropriate, data regarding each risk factor will be pooled through a random-effect meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to evaluate the overall quality of evidence.Ethics and disseminationTo our knowledge, this will be the first systematic review evaluating risk factors for prevalent and incident delirium specifically related to the ED setting. Results of this study will aid in the identification of older adults at risk for delirium in the ED. We aim to publish the results of this systematic review in a peer-reviewed journal with good visibility for the fields of emergency medicine and geriatrics.PROSPERO registration numberCDR42020175261

Heterotopic Ossification (HO) refers to the formation of bone within soft tissue. Traumatic spinal cord injury (SCI) has been shown to be associated with development of HO. However, risk factors for HO following SCI are unknown. In light of this knowledge gap, we performed a systematic review and meta-analysis to summarize available evidence and elucidate risk factors associated with heterotopic ossification. An electronic literature search was conducted using five databases. Studies containing SCI patients, with a proportion diagnosed with HO, were included. Meta-analyses were performed to assess the association between following risk factors and development of HO: sex, type of injury, spasticity, pressure ulcer, injury level, urinary tract infection (UTI), deep vein thrombosis (DVT), number of smokers, and pneumonia. Nine studies with 2,115 patients were included. It was found that males (Odds Ratio [95% Confidence Interval]: 2.25 [1.61, 3.13]), smokers (2.88 [1.62, 5.11]), patients with complete injury (3.61 [2.29, 5.71]), pneumonia (2.86 [2.18, 3.75]), pressure ulcers (2.45 [1.89, 3.18]), UTI (3.84 [2.63, 5.62]) and spasticity (2.12 [1.67, 2.68]) had significantly higher odds of developing HO after spinal cord injury. In contrast, location of injury (Cervical vs. thoracic injury; (1.03 [0.72, 1.49]) and DVT (1.37 [0.91, 2.07]) were not associated with development of HO. Pooled results from existing literature on HO development show that several factors are significantly associated with development of HO. Given the complexity of SCI management, the results might have a positive impact on the clinical practice by leading to an effective screening aproach.

Inflammatory Bowel Disease (IBD) is a chronic autoimmune disorder that disturbs the digestive tract with fluctuating periods of active disease and remission. Crohn’s Disease and ulcerative colitis ...

Heterotopic ossification(HO) is a common complication following spinal cord injury(SCI); however, its underlying pathophysiology remains relatively unknown. Although there are options for treating HO, prophylactic treatment is limited. Additionally, evidence supporting the effectiveness of these prophylactic treatments is scarce. Electronic literature search was conducted using four databases. Studies comparing prophylactic medication for HO versus placebo for patients with acute spinal cord injury were included. A meta-analysis comparing the incidence of HO between the two groups was conducted, with a subgroup analysis of non-steroidal anti-inflammatory drugs (NSAIDs) and non-NSAIDs. A total of 5 studies and 815 patients were included. Overall incidence of HO was 9.73 % (n = 25) in the medication group versus 16.5 %(n = 92) in the placebo group. However, the two groups do not statistcally differ(p = 0.21). In the subgroup analysis for NSAIDs, those who received prophylactic treatment with NSAIDs had a lower incidence of HO compared to those who received placebo (RR[95 % CI]:0.32[0.15, 0.68]; p = 0.003). As for studies that used bisphosphonates, a statistically significant difference in incidence of HO was not found (RR[95 % CI]:1.30[0.52, 3.24];p = 0.58) and the overall evidence was inconclusive. In present systematic review and meta-analysis comparing prophylactic medications to placebo for prevention of HO, we found similar incidence rates for both groups. However, subgroup analysis showed a significantly lower incidence rate for those who recevied NSAIDs for HO prophylaxis. Altough this finding is promising for secondary prevention of HO among patients suffering from SCI, further prospective studies with longer follow-ups are required to assess other appropriate medications for HO prevention.