The effect of nature exposure on pain experience and quality of life in patients with chronic pain: A systematic review and meta-analysis protocol.

BACKGROUND: Chronic pain is a complex condition with short and long-term effects on physical and psychosocial health. Nature exposure therapy has been investigated as a potential non-pharmacological intervention to improve physical and emotional health of individuals with chronic pain. This proposed systematic review aims to examine the effects of nature exposure therapy on pain experience and quality of life in patients with chronic pain. METHODS: Studies will be identified by searching the MEDLINE, Embase and Cumulative Index for Nursing and Allied Health Literature (CINAHL) databases. All included studies will be required to be interventional controlled trials comparing nature exposure therapy to placebo or standard care in patients with chronic pain. Primary outcomes for this review will be pain intensity and quality of life scores. Secondary outcomes will include self-efficacy, depression and pain-related anxiety scores. If 2 or more studies are included, results will be pooled for meta-analysis. If meta-analysis is not possible, the results will be presented in a narrative form. DISCUSSION: Given the adverse effects of opioid use, non-pharmacological interventions are a necessary alternative to treat patients with chronic pain. Nature exposure therapy is an intriguing example of such an intervention. We hope that this systematic review will guide future clinical decision-making for patients with chronic pain and provide evidence for or against the need for natural spaces and improved urban planning. TRIAL REGISTRATION: PROSPERO registration number: CRD42021226949.

Simulation Training in the Management of Adverse Contrast Reactions: A Systematic Review.

BACKGROUND: Simulation-based training has become increasingly prominent within medical education, but its utility within radiology remains underexplored. OBJECTIVE: To appraise the evidence for the effectiveness of simulation on the management of adverse reactions to contrast media. METHODS: A systematic search of the literature was conducted. Eligible studies recruited radiology residents, provided simulation-based training focused on contrast reaction management, and measured any effectiveness outcome compared with any nonsimulation training or no training. The quality of studies was appraised and outcomes were classified according to Kirkpatrick's hierarchy and the strength of evidence. RESULTS: Out of 146 screened results, 15 articles were included that described 17 studies-3 randomized trials and 14 pretest-posttest studies of hands-on or, less commonly, computer-based simulation. In all 16 studies that assessed knowledge before and after intervention, written test scores improved after simulation. Most studies noted improvements in comfort or confidence managing contrast reactions as well. In all three studies that assessed knowledge after simulation and after didactic lecture as a control, posttest scores were not statistically significantly better in the simulation groups than the lecture groups. Common study limitations included single-group designs, measuring only learning outcomes using unvalidated instruments, modest sample sizes, and limited assessment of long-term retention. CONCLUSION: Simulation produces subjective improvements and knowledge gain relevant to contrast reaction management. Further research is required to demonstrate superiority of simulation-based contrast reaction management training over traditional didactic lecture-based instruction.

First-Onset Psychosis After COVID-19 Infection: A Systematic Review of the Literature.

BACKGROUND: The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP). OBJECTIVE: The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP. METHODS: A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria. RESULTS: Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms. CONCLUSIONS: This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly.

The Effects of Intraoperative Methadone on Postoperative Pain Control in Pediatric Patients: A Scoping Review.

Inadequate perioperative pain control has deleterious effects on children's development and can lead to heightened pain experiences and the avoidance of future medical procedures. Reports of perioperative use of methadone in children are increasing, as it has a favorable pharmacodynamic profile; however, the effectiveness of methadone in reducing postoperative pain has not been established. We, therefore, aimed to provide a scoping review of the literature comparing the effect of intraoperative methadone versus other opioids on postoperative opioid consumption, pain scores, and adverse events in pediatric patients. We identified studies in PubMed, Scopus, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to January 2023. Postoperative opioid consumption, pain scores, and adverse events were extracted for analysis. We screened 1864 studies, of which 83 studies were selected for full-text review. Five studies were included in the final analysis. Postoperative opioid consumption was decreased overall in children who received methadone compared to those who did not. The majority of studies indicated that methadone was superior to other opioids in reported pain scores, while the frequency of adverse events was similar between the groups. Although the data reviewed highlight a potential benefit of intraoperative methadone in pediatric patients, 4 of the 5 studies had serious methodological concerns. Thus, we cannot make strong recommendations for the regular use of methadone in the perioperative setting at this time. Our results highlight the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse pediatric surgical populations.

Social Determinants of Health in Pediatric Rehabilitation for Children with Traumatic Injury: A Systematic Review.

OBJECTIVE: To examine the current evidence regarding health care disparities in pediatric rehabilitation after hospitalization with traumatic injury. STUDY DESIGN: This systematic review utilized both PubMed and EMBASE, and each was searched with key MESH terms. Studies were included in the systematic review if they (1) addressed social determinants of health including, but not limited to, race, ethnicity, insurance status, and income level; (2) focused on inpatient and outpatient rehabilitation services posthospital stay; (3) were based in the pediatric population; and (4) addressed traumatic injury requiring hospitalization. Only studies from within the US were included. RESULTS: From 10 169 studies identified, 455 abstracts were examined for full-text review, and 24 studies were chosen for data extraction. Synthesis of the 24 studies revealed 3 major themes: (1) access to services; (2) outcomes from rehabilitation; and (3) service provision. Patients with public insurance had decreased availability of service providers and had longer outpatient wait times. Non-Hispanic Black and Hispanic children were more likely to have greater injury severity and decreased functional independence after discharge. Lack of interpreter services was associated with decreased utilization of outpatient services. CONCLUSIONS: This systematic review identified significant effects of health care disparities on the rehabilitation process in pediatric traumatic injury. Social determinants of health must be thoughtfully addressed to identify key areas of improvement for the provision of equitable health care.

Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation.

BACKGROUND: Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation. OBJECTIVE: The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation. METHODS: Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for. RESULTS: The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n = 10), the general medical patient (n = 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n = 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use. CONCLUSIONS: Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.

Neuroimaging Correlates of Post-Traumatic Stress Disorder in Traumatic Brain Injury: A Systematic Review of the Literature.

Neuroimaging is widely utilized in studying traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The risk for PTSD is greater after TBI than after non-TBI trauma, and PTSD is associated with worse outcomes after TBI. Studying the neuroimaging correlates of TBI-related PTSD may provide insights into the etiology of both conditions and help identify those TBI patients most at risk of developing persistent symptoms. The objectives of this systematic review were to examine the current literature on neuroimaging in TBI-related PTSD, summarize key findings, and highlight strengths and limitations to guide future research. A Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) compliant literature search was conducted in PubMed (MEDLINE®), PsycINFO, Embase, and Scopus databases prior to January 2022. The database query yielded 4486 articles, which were narrowed based on specified inclusion criteria to a final cohort of 16 studies, composed of 854 participants with TBI. There was no consensus regarding neuroimaging correlates of TBI-related PTSD among the included articles. A small number of studies suggest that TBI-related PTSD is associated with white matter tract changes, particularly in frontotemporal regions, as well as changes in whole-brain networks of resting-state connectivity. Future studies hoping to identify reliable neuroimaging correlates of TBI-related PTSD would benefit from ensuring consistent case definition, preferably with clinician-diagnosed TBI and PTSD, selection of comparable control groups, and attention to imaging timing post-injury. Prospective studies are needed and should aim to further differentiate predisposing factors from sequelae of TBI-related PTSD.

Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review.

OBJECTIVE: The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS: This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS: A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS: High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.

Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review.

OBJECTIVE: Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions. DATA SOURCES: PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus. STUDY SELECTION: We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication. DATA EXTRACTION: Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. DATA SYNTHESIS: Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions. CONCLUSIONS: Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.

Safety of Scrambler Therapy: A Systematic Review of Complications and Adverse Effects.

OBJECTIVE: The objective was to qualitatively synthesize all reported cases of complications, adverse effects, side effects, or harms arising from the use of scrambler therapy (ST). METHODS AND DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The PubMed, Embase, Scopus, Web of Science, United States National Library of Medicine clinical trials registry, and Cochrane Central Register of Controlled Trials databases were searched from database inception to December 10, 2021. Case reports/series, abstracts, retrospective studies, and prospective studies (e.g., open-label trials, randomized controlled trials) pertaining to ST and any description of a complication, adverse effect, side effect, or harm were screened. The search protocol was developed a priori and registered via the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42021291838). RESULTS: A total of six RCTs, 19 prospective open-label trials, and 11 case series / case reports met the inclusion criteria, comprising 1,152 total patients. Two patients experienced contact dermatitis, and one patient reported minor ecchymosis that resolved without intervention. This yielded a composite complication rate of 0.26% (3/1,152). There were zero reported serious adverse events. CONCLUSIONS: When used in accordance with the treatment protocols described by the United States Food and Drug Administration and device manual, ST is associated with a reported composite complication rate that is orders of magnitude lower than those of invasive neuromodulation devices. ST neuromodulation is a safe alternative for patients who cannot undergo invasive neuromodulation device implantation because of either risk or preference.

A cross-sectional study of participant recruitment rates in published phase III influenza therapeutic randomized controlled trials conducted in the clinical setting.

OBJECTIVE: A recent academic-government partnership demonstrated the feasibility of utilizing Emergency Departments (ED) as a primary site for subject enrollment in clinical trials and achieved high rates of recruitment in two U.S. EDs. Given the ongoing need to test new therapeutics for influenza and other emerging infections, we sought to describe the historical rates of participant recruitment into influenza Phase III therapeutic RCTs in various clinical venues, including EDs. STUDY DESIGN: A cross-sectional study was performed of influenza therapeutic Phase III RCTs published in PubMed, Embase, Scopus, and Clinicaltrials.gov from January 2000 to June 2019. MAIN OUTCOME: To estimate the weighted-average number of influenza-positive participants enrolled per site per season in influenza therapeutic RCT conducted in clinical settings, and to describe basic trial site characteristics. RESULTS: 47 (0.7%) of 7008 articles were included for review of which 43 of 47 (91%) included information regarding enrollment sites; of these, 2 (5%) recruited exclusively from EDs with the remainder recruiting from mixed clinical settings (inpatient, outpatient, and ED). The median enrollment per study was 326 (IQR: 110, 502.5) with a median of 11 sites per study (IQR: 2, 59.5). Included studies reported a median of 201 (IQR: 74, 344.5) confirmed influenza-positive participants per study. The pooled number of participants enrolled per site per season was 11 (95% CI: 10, 12). The pooled enrollment numbers per clinical site after excluding the two 'ED only recruitment' studies were less [10.7 (95% CI: 9.9, 11.6)] than the pooled enrollment numbers per clinical site for the two 'ED only recruitment' studies [89.5 (95% CI 89.2-89.27)]. CONCLUSION AND RELEVANCE: Published RCTs evaluating influenza therapeutics in clinical settings recruit participants from multiple sites but enroll relatively few participants, per site, per season. The few ED-based studies reported recruited more subjects per site per season. Untapped opportunities likely exist for EDs to participate and/or lead therapeutic RCTs for influenza or other emerging respiratory pathogens.

Behavioral and Emotional Dyscontrol Following Traumatic Brain Injury: A Systematic Review of Neuroimaging and Electrophysiological Correlates.

BACKGROUND: Behavioral and emotional dyscontrol commonly occur following traumatic brain injury (TBI). Neuroimaging and electrophysiological correlates of dyscontrol have not been systematically summarized in the literature to date. OBJECTIVE: To complete a systematic review of the literature examining neuroimaging and electrophysiological findings related to behavioral and emotional dyscontrol due to TBI. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search was conducted in PubMed (MEDLINE), PsycINFO, EMBASE, and Scopus databases prior to May 2019. The database query yielded 4392 unique articles. These articles were narrowed based on specific inclusion criteria (e.g., clear TBI definition, statistical analysis of the relationship between neuroimaging and dyscontrol). RESULTS: A final cohort of 24 articles resulted, comprising findings from 1552 patients with TBI. Studies included civilian (n = 12), military (n = 10), and sport (n = 2) samples with significant variation in the severity of TBI incorporated. Global and region-based structural imaging was more frequently used to study dyscontrol than functional imaging or diffusion tensor imaging. The prefrontal cortex was the most common neuroanatomical region associated with behavioral and emotional dyscontrol, followed by other frontal and temporal lobe findings. CONCLUSIONS: Frontal and temporal lesions are most strongly implicated in the development of postinjury dyscontrol symptoms although they are also the most frequently investigated regions of the brain for these symptom categories. Future studies can make valuable contributions to the field by (1) emphasizing consistent definitions of behavioral and emotional dyscontrol, (2) assessing premorbid dyscontrol symptoms in subjects, (3) utilizing functional or structural connectivity-based imaging techniques, or (4) restricting analyses to more focused brain regions.

Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS.

Purpose of Review: To discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management. Recent Findings: The recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance). Summary: We do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms. Supplementary Information: The online version contains supplementary material available at 10.1007/s40124-022-00261-4.

Bibliometric analysis of interventional radiology studies in PubMed-indexed literature from 1991 to 2020.

PURPOSE: To evaluate interventional radiology (IR) research over time based on the study type of published articles and the visibility of articles to non-radiology clinicians. METHODS: We performed a search of all PubMed-indexed literature from January 1, 1991, through November 11, 2020, for clinical IR articles classified by their study type, categorized as: 1) meta-analyses/systematic reviews/practice guidelines; 2) randomized controlled trials; 3) non-randomized controlled trials; and 4) longitudinal/observational studies. Clinical IR articles were defined as those that met keyword criteria constructed from Society of Interventional Radiology procedure guides. Data were also collected on medical specialty journal categories that published IR-related articles. RESULTS: When we examined the first vs. the last decade of our study period, the number of IR articles published increased across all study types: randomized controlled trials (374 to 2620; 601% change), longitudinal/observational studies (2324 to 12,447; 436%), meta-analyses/systematic reviews/practice guidelines (1179 to 6135; 420%), non-randomized controlled trials (471 to 2161; 359%). The journal categories with the highest mean percentage increase of IR articles across all study types were obstetrics and gynecology (659%), peripheral vascular disease (342%), and emergency medicine (221%). We found a decrease of IR articles published in surgery (-6.0%), pediatrics (-14%), and pulmonary (-21%) journals. CONCLUSION: The number of IR articles grew quickly and at a similar rate compared with all PubMed-indexed articles and increased as a proportion of articles published in non-imaging specialty journals. This indicates greater visibility of IR studies for all clinicians and is encouraging towards the advancement of IR techniques.

Medication Errors in Overweight and Obese Pediatric Patients: A Narrative Review.

BACKGROUND: The childhood obesity epidemic in the United States has increased utilization of health care and prescribing of medications in overweight and obese children, yet it is unclear whether this has led to more medication errors. The objective of this study was to review all available literature on incidence and types of medication errors in overweight and obese children. METHODS: A search of MEDLINE, Embase, and Scopus databases was conducted for all studies and oral abstracts through December 2020 reporting medication errors in overweight or obese children aged ≤ 18 years. All studies were identified and extracted via a Covidence database. Two reviewers independently reviewed studies and rated the methodologic quality of those included per GRADE (Grading of Recommendations, Assessment, Development and Evaluations) criteria. RESULTS: The search identified 1,016 abstracts from databases. Following review, full text was obtained for 146 articles, of which 141 were excluded. A total of 5 studies met criteria for inclusion and described dosing errors of antimicrobials, anesthetics, and paracetamol in overweight and obese pediatric patients. Two of the 5 studies compared medication errors in obese to nonobese children, and both found that medication errors (both over- and underdosing) were generally more common among obese children. The identified reasons for medication errors included incorrect dosing weight, incorrect dosing strategy, over- and underdosing with weight-based and flat-fixed dosing, and inapposite use of age-based dosing schemas. CONCLUSION: There is a paucity of patient safety evidence available evaluating medication use in overweight and obese children and associated medication errors. Overweight and obese children may be at increased risk of medication errors, although the clinical significance of this is unknown.

Neuroimaging Correlates of Syndromal Anxiety Following Traumatic Brain Injury: A Systematic Review of the Literature.

BACKGROUND: Traumatic brain injury (TBI) can precipitate new-onset psychiatric symptoms or worsen existing psychiatric conditions. To elucidate specific mechanisms for this interaction, neuroimaging is often used to study both psychiatric conditions and TBI. This systematic review aims to synthesize the existing literature of neuroimaging findings among patients with anxiety after TBI. METHODS: We conducted a Preferred Reporting Items for Systematic Review and Meta-Analyses-compliant literature search via PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases before May, 2019. We included studies that clearly defined TBI, measured syndromal anxiety as a primary outcome, and statistically analyzed the relationship between neuroimaging findings and anxiety symptoms. RESULTS: A total of 5982 articles were retrieved from the systematic search, of which 65 studied anxiety and 13 met eligibility criteria. These studies were published between 2004 and 2017, collectively analyzing 764 participants comprised of 470 patients with TBI and 294 non-TBI controls. Imaging modalities used included magnetic resonance imaging, functional magnetic resonance imaging, diffusion tensor imaging, electroencephalogram, magnetic resonance spectrometry, and magnetoencephalography. Eight of 13 studies presented at least one significant finding and together reflect a complex set of changes that lead to anxiety in the setting of TBI. The left cingulate gyrus in particular was found to be significant in 2 studies using different imaging modalities. Two studies also revealed perturbances in functional connectivity within the default mode network. CONCLUSIONS: This is the first systemic review of neuroimaging changes associated with anxiety after TBI, which implicated multiple brain structures and circuits, such as the default mode network. Future research with consistent, rigorous measurements of TBI and syndromal anxiety, as well as attention to control groups, previous TBIs, and time interval between TBI and neuroimaging, are warranted. By understanding neuroimaging correlates of psychiatric symptoms, this work could inform future post-TBI screening and surveillance, preventative efforts, and early interventions to improve neuropsychiatric outcomes.

Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP. METHODS: MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI). RESULTS: Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively. CONCLUSION: Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.

Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary.

Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Melatonin Use in Hospitalized Children for Non-Anesthetic Indications: A Systematic Review.

Melatonin, a potent free radical scavenger, plays an important role in homeostasis of cell and organ physiology. The increased demand and synthesis from the pineal gland during times of oxidative stress suggests a potential benefit of melatonin supplementation during hospitalization for acute illness. Yet, the paucity of clinical studies for non-anesthetic-associated indications in pediatric populations hampers the safe, effective, and consistent use of melatonin. The objective of this study was to systematically review published studies of melatonin use for non-sedative and non-analgesic indications in hospitalized pediatric patients. We conducted a search of PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Scopus databases for articles on the use of melatonin for pediatric patients in a hospital setting. Thirteen eligible studies, all in neonates, were identified. Data elements extracted included study design, number of study subjects, indication for melatonin therapy, and melatonin regimen (formulation, dosage, and duration). Because study methodologies were very heterogeneous, a quantitative synthesis of the published findings was not possible. The identified studies were therefore categorized by the indication of melatonin (adjuvant-antioxidant or anti-inflammatory therapy) in the following specific disease states: (i) acute infections, (ii) respiratory distress syndrome, (iii) neurologic injury, and (iv) jaundice. The current data suggest that melatonin is safe for use in hospitalized neonates. Melatonin may be beneficial for reducing inflammatory markers in neonatal patients with disease states and clinical sequelae that are associated with increased inflammation and oxidative stress. Melatonin, in conjunction with phototherapy, is not superior to use of vitamin D with phototherapy for treatment of neonatal jaundice. However, studies in other pediatric populations are needed given widespread use across clinical inpatient settings.