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Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Importance The continued harm of Black individuals in the US by law enforcement officers calls for reform of both law enforcement officers and structural racism embedded in communities. Objective To examine the association between county characteristics and racial and ethnic disparities in legal intervention injuries. Design, Setting, and Participants This retrospective, cross-sectional study was conducted among 27 671 patients presenting to California hospitals from January 1, 2016, to December 31, 2019, with legal intervention injuries (defined as any injury sustained as a result of an encounter with any law enforcement officer) as identified byInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revisioncodes. Main Outcomes and Measures Legal intervention injuries were classified byInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revisionexternal cause of injury code Y35. Expected injury counts were calculated for each county by multiplying statewide median rates of injury per capita for each age–racial and ethnic group, and then observed to expected injury ratios were measured. The association between county injury ratio, percentage of Black individuals, and residential segregation (measured using an index of dissimilarity) was modeled, stratifying by race and ethnicity. Results A total of 27 671 patients (24 159 male patients [87.3%]; 1734 Asian and Pacific Islander [6.3%], 5049 Black [18.2%], 11 250 Hispanic [40.7%], and 9638 White [34.8%]; mean [SD] age, 34.2 [12.5] years) presented with legal intervention injuries in California from 2016 to 2019. Observed to expected injury ratios ranged from 0 to 7 for Black residents and from 0 to 5 for White residents. High observed to expected injury ratios for Black residents (408 observed vs 60 expected; ratio = 7) were clustered around San Francisco Bay Area counties and corresponded with a higher proportion of Black residents. High observed to expected injury ratios for White residents (57 observed vs 11 expected; ratio = 5) clustered around rural northern California counties and corresponded with higher mean percentage of residents with income below the federal poverty level and fewer urban areas. Conclusions and Relevance This study suggests that residential segregation may be associated with increased legal intervention injury rates for Black residents of California counties with a large percentage of Black residents. Reform efforts to address racial and ethnic disparities in these injuries should carefully consider and address the legacy of discriminatory policies that has led to segregated communities in California and the United States.

Background Prior studies of patients in the intensive care unit have suggested racial/ethnic variation in end-of-life decision making. We sought to evaluate whether race/ethnicity modifies the implementation of comfort measures only status (CMOs) in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH). Methods We analyzed data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective cohort study specifically designed to enroll equal numbers of white, black, and Hispanic subjects. ICH patients aged ≥ 18 years were enrolled in ERICH at 42 hospitals in the USA from 2010 to 2015. Univariate and multivariate logistic regression analyses were implemented to evaluate the association between race/ethnicity and CMOs after adjustment for potential confounders. Results A total of 2705 ICH cases (912 black, 893 Hispanic, 900 white) were included in this study (mean age 62 [SD 14], female sex 1119 [41%]). CMOs patients comprised 276 (10%) of the entire cohort; of these, 64 (7%) were black, 79 (9%) Hispanic, and 133 (15%) white (univariate p  < 0.001). In multivariate analysis, compared to whites, blacks were half as likely to be made CMOs (OR 0.50, 95% CI 0.34–0.75; p  = 0.001), and no statistically significant difference was observed for Hispanics. All three racial/ethnic groups had similar mortality rates at discharge (whites 12%, blacks 9%, and Hispanics 10%; p  = 0.108). Other factors independently associated with CMOs included age ( p  < 0.001), premorbid modified Rankin Scale ( p  < 0.001), dementia ( p  = 0.008), admission Glasgow Coma Scale ( p  = 0.009), hematoma volume ( p  < 0.001), intraventricular hematoma volume ( p  < 0.001), lobar ( p  = 0.032) and brainstem ( p  < 0.001) location and endotracheal intubation ( p  < 0.001). Conclusions In ICH, black patients are less likely than white patients to have CMOs. However, in-hospital mortality is similar across all racial/ethnic groups. Further investigation is warranted to better understand the causes and implications of racial disparities in CMO decisions.