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Background: A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN., Methods: We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed., Results: From 149 titles, five systematic reviews were selected for quality assessment, and two reviews were of higher methodological quality and were included. These two reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of two RCTs including a total of 50 patients, the use of corticosteroids (compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% confidence interval [CI] 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide CI for the outcome of dizziness handicap score (one study, 30 patients, 20.9 points in corticosteroids group vs. 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low., Conclusions: There is limited evidence to support the use of corticosteroids for the treatment of VN in the emergency department., (© 2022 Society for Academic Emergency Medicine.)

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., (© 2021 Society for Academic Emergency Medicine.)

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., (© 2021 Society for Academic Emergency Medicine.)