Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 25 appraisals
European journal of emergency medicine : official journal of the European Society for Emergency Medicine
Effect of a liquid crystal vein locator on intravenous catheterization in young children: a randomized trial
BACKGROUND AND IMPORTANCE: Peripheral intravenous catheterization (PIVC) in young children is notoriously challenging because of factors like poor patient cooperation and small vessel diameter. Repeated attempts cause distress and delay critical emergency treatment. OBJECTIVES: This study aimed to evaluate the effect of a novel liquid crystal display-based near-infrared vein locator on PIVC performance in children aged under 3 years. DESIGN: This is a prospective, randomized controlled trial. SETTINGS AND PARTICIPANTS: A total of 105 children aged 0-3 years requiring PIVC were enrolled in a pediatric emergency department. INTERVENTION: Participants were randomly assigned to undergo PIVC using either a liquid crystal vein locator (study group, n = 50) or the traditional landmark-based method (control group, n = 55). OUTCOME MEASURES AND ANALYSIS: The primary endpoint was the first-attempt success rate. Secondary endpoints included the number of puncture attempts, vein localization time, and total insertion time. Multivariable logistic and Poisson regression models were used to adjust for covariates, such as vein difficulty and patient demographics. Analyses included effect sizes with 95% confidence intervals (CIs). MAIN RESULTS: The baseline characteristics of both groups were comparable. The first-attempt success rate was significantly higher in the study group compared to the control group (86.0% vs. 54.5%; absolute difference: 31.5%; 95% CI: 15.2-47.8%). The study group also demonstrated a significantly shorter median vein localization time (16.5 vs. 60.0 s) and median total insertion time (40.0 vs. 185.0 s). In addition, the device significantly reduced the median number of puncture attempts (adjusted rate ratio: 0.77; 95% CI: 0.66-0.90). Multivariable analysis revealed that device assistance was an independent predictor of first-attempt success (adjusted odds ratio: 3.35; 95% CI: 1.13-9.95). CONCLUSION: In this study, the use of a liquid crystal vein locator was associated with a significantly higher first-attempt success rate, fewer puncture attempts, and reduced procedural times for PIVC in young children.
24 June 2026
Read appraisal →BMJ open
Difficult intravenous access (DIVA) in the adult population: an umbrella review.
OBJECTIVES: To synthesise evidence from systematic reviews on difficult intravenous access (DIVA) in adults, focusing on definitions, diagnostic criteria, risk factors and clinical interventions to guide clinical practice and health policy. DESIGN: Umbrella review of systematic reviews and meta-analyses. SETTING: Any clinical setting involving adult patients requiring peripheral venous access (including hospital, emergency and outpatient care). DATA SOURCES: A systematic search was performed in PubMed, CINAHL, Cochrane, Scopus and Web of Science in July 2025. ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses published from 2014 to 2025 that addressed DIVA in the adult population were included. Primary studies and protocols were excluded. DATA EXTRACTION AND SYNTHESIS: Methodological quality was assessed using the Risk Of Bias In Systematic Reviews tool. Data extraction followed the Joanna Briggs Institute methodology for overviews and the Preferred Reporting Items for Overviews of Reviews reporting guideline. RESULTS: Seven reviews (six systematic reviews and one meta-analysis) were included. Three analytical dimensions emerged: (1) the conceptual and operational definition of DIVA, identifying common elements such as ≥2 failed attempts, lack of visible or palpable veins and a documented history of difficult access; (2) risk factors and clinical assessment, highlighting obesity, chronic diseases, prior chemotherapy, venous invisibility or non-palpability and the limited validation of diagnostic tools and (3) interventions, including organisational strategies (escalation protocols, specialised teams), technological resources (ultrasound guidance) and clinical measures (pain management and technique optimisation). CONCLUSIONS: DIVA is a multifactorial challenge that requires a standardised definition to improve clinical identification. Effective management relies on a combination of specialised training, the use of ultrasound technology and the implementation of escalation protocols to ensure patient safety and efficiency. PROSPERO REGISTRATION NUMBER: CRD420251084947.
14 June 2026
Read appraisal →The journal of ECT
Comparison of the Effects of Dexmedetomidine and Remifentanil on Seizure Duration, Hemodynamics, and Recovery Time in Electroconvulsive Therapy
OBJECTIVES: Electroconvulsive therapy (ECT) is an important treatment method that is widely used in psychiatric conditions resistant to pharmacological treatments. METHODS: This prospective, randomized study included 100 patients undergoing ECT. Group D received dexmedetomidine and propofol, while group R received remifentanil and propofol. In this study, key parameters such as seizure duration, hemodynamic changes, and recovery time were analyzed. RESULTS: The investigation revealed no statistically significant differences between the groups with regard to mean age, gender distribution, or seizure duration ( P > 0.05). Subsequent to induction, group R exhibited statistically significantly lower systolic blood pressure, diastolic blood pressure, and mean arterial pressures in comparison to group D ( P < 0.05). Conversely, heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure levels in group R were found to be statistically significantly higher than in group D ( P < 0.05). The recovery time in group D was found to be statistically significantly longer than in group R ( P < 0.05). CONCLUSIONS: Dexmedetomidine provides superior hemodynamic stability, while remifentanil ensures faster recovery. Dexmedetomidine has been shown to be more advantageous in terms of hemodynamic stability, while remifentanil has been demonstrated to result in shorter recovery times. Clinicians should tailor anesthetic choices based on patient profiles and therapeutic goals.
30 May 2026
Read appraisal →Prehospital and disaster medicine
Evaluating Nursing Students' Performance and Retention of BLS/AED Knowledge and Skills One Year After Training: A Randomized Controlled Trial
INTRODUCTION: Nurses often serve as the initial responders in cases of cardiac arrest, making cardiopulmonary resuscitation (CPR) competence essential to effective resuscitation. It is therefore important for nursing students to possess sufficient CPR knowledge and skills for future clinical practice. OBJECTIVE: The aim of this study was to examine whether CPR post-qualification training is needed in maintaining knowledge and skills and if face-to-face or online training is more effective as an educational method in preserving CPR knowledge and skills in nursing students. METHODS: A three-group, parallel randomized-controlled, single-blind design was used. The participants were 133 nursing students, randomly assigned to the face-to-face group (n = 43), the e-learning group (n = 43), and the control group (n = 47). Before randomization, all participants (n = 133) successfully completed the European Resuscitation Council (ERC) standard five-hour Basic Life Support/Automated External Defibrillation (BLS/AED) course (t0) and a questionnaire based on the 2021 ERC Guidelines to assess their knowledge. Six months later, Group A received face-to-face training, Group B received e-learning training, and Group C had no intervention. Six months after interventions, all participants (n = 133) were re-assessed on the same questionnaire, and they were given the same scenario of cardiopulmonary arrest that was used during the initial BLS course to assess the skills that they retained (t1) with the use of the ERC CPR/AED 11-item checklist. The collected data were analyzed with inferential "among group" analysis involving Kruskal-Wallis's and Pearson's Chi-Squared test and inferential "within group" analysis including Wilcoxon's Signed-Rank and McNemar's test. Multiple linear regression was used for adjusting demographic characteristics. RESULTS: Based on pairwise differences between independent groups, both intervention groups presented higher scores in knowledge at t1 (P < 0.001) and in skills at t1 (P < 0.001) compared to the control group. Moreover, both training methods demonstrated comparable effectiveness. Based on comparisons between paired groups, there was also a statistically significant decrease in the Skill Score in the control group after one year (P < 0.001). Most skills were notably higher, primarily in the e-learning group, and to a lesser extent in the face-to-face group. In specific, intervention groups demonstrated statistically significant improvement in nine of the eleven assessed skills (all P < 0.05). CONCLUSION: The current study showed that post-qualification training is needed to retain CPR knowledge and skills of nursing students, and that face-to-face and e-learning training had similar outcomes.
23 May 2026
Read appraisal →JMIR formative research
Application of an AI-Based Pediatric Early Warning Score in the Pediatric Emergency Department: Cross-Sectional Study
BACKGROUND: Pediatric emergency departments see a high volume of patients. Given that children often cannot describe their condition and there is a shortage of nursing staff, it is essential to identify the early warning signs of adverse conditions among children as quickly as possible. Current targeted care needs to be improved. OBJECTIVE: This study aimed to investigate the application of an artificial intelligence (AI)-based version of the Pediatric Early Warning Score (PEWS) in a pediatric emergency observation unit, analyze the relationship between PEWS and disease severity, and assess its impact on the length of hospital stay and hospitalization costs after admission, thereby providing a reference for targeted nursing care. METHODS: We performed a retrospective study. A total of 1233 pediatric patients admitted via the pediatric emergency department of a tertiary specialty hospital in Guangzhou from September 2023 to March 2024 were included. The patients were divided according to whether they triggered a PEWS early warning into an early warning group (PEWS ≥1) and a non-early warning group (PEWS=0) during emergency observation. Length of stay and hospitalization costs were compared between the early warning group and the non-early warning group. Differences between groups were assessed using the Mann-Whitney U test. We performed multivariable logistic regression to discuss the association of resource use metrics and PEWS status, adjusted by age, sex, and disease category (respiratory, neurological, and hematologic). RESULTS: Of 1233 patients, 597 (48.4%) triggered the PEWS early warning (mean score 2.44, SD 1.41), and 636 (51.6%) did not. In the early warning group, 68 children were transferred to the intensive care unit, with a mean PEWS of 3.32 (SD 1.73). Compared with the non-early warning group, the early warning group had a longer hospital stay (z=-5.180; P<.001) and higher hospitalization costs (z=-6.500; P<.001), and the differences between groups were statistically significant (P<.001). Among the top 3 admission categories-respiratory, neurological, and hematologic diseases-children in the early warning group had significantly longer hospital stays and higher hospitalization costs (all P<.01). The β coefficient for length of hospital stay was 0.053 (SE 0.010; Wald χ²1=5.533; odds ratio 1.055, 95% CI 1.035-1.075), while the β coefficient for hospitalization costs was 0.001 (SE 0.000; Wald χ²1=6.075; odds ratio 1.001, 95% CI 1.001-1.001). CONCLUSIONS: Compared with the non-early warning group, the early warning group had significantly longer hospital stays and higher hospitalization costs (P<.001); similar patterns were observed within respiratory, neurological, and hematologic disease categories (all P<.01). These findings show differences between children who triggered the warning and children who did not, providing a reference for identifying critically ill children for targeted care.
21 May 2026
Read appraisal →Renal failure
Machine learning-based risk prediction model for postoperative acute kidney injury in surgical patients with chronic kidney disease (CKD): development, validation, and SHAP-based explainability
This study aimed to develop machine learning models to predict postoperative acute kidney injury (AKI) in surgical patients with pre-existing chronic kidney disease (CKD), a serious complication associated with high morbidity and accelerated disease progression. Using data from 3,851 surgical patients with CKD from the MIMIC-IV database, nine supervised machine learning models were developed to predict AKI, as defined by the KDIGO criteria. Postoperative AKI occurred in 24.2% (932/3,851) of the patients. The XGBoost model demonstrated the best predictive performance, achieving an AUC of 0.844, accuracy of 0.791, sensitivity of 0.79, and F1-score of 0.73, followed by Random Forest and LightGBM. The calibration curve showed a good agreement between the predicted and observed risks. For interpretability, SHAP analysis was used to identify SOFA score, estimated glomerular filtration rate (eGFR), systolic blood pressure, albumin, and phosphorus as the most influential predictors. In conclusion, machine learning models, particularly XGBoost, provide accurate and interpretable predictions of postoperative AKI in this high-risk population. The integration of explainable AI facilitates transparent risk stratification, which may support personalized perioperative care and the development of real-time clinical decision support systems.
21 May 2026
Read appraisal →Journal of neurointerventional surgery
Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial
BACKGROUND: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial. METHODS: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed. RESULTS: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05). CONCLUSION: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.
16 May 2026
Read appraisal →Proceedings of the National Academy of Sciences of the United States of America
Speed and quality of complex strategic decisions
Many strategic decisions involve both substantial complexity and time pressure, but the association between decision speed and decision quality of cognitively demanding strategic decisions is not well understood. This paper presents evidence on this question using a setting with exceptionally detailed and precise information about decision times and decision quality-it analyses move-by-move data from in-person professional chess tournaments. Decision quality is measured by comparing actual moves to a computational benchmark of best moves constructed using the artificial intelligence of a chess engine. The results show that faster decisions are associated with higher decision quality, even after accounting for computational complexity, distinctiveness between alternatives, and time pressure. Greater computational complexity and lower distinctiveness between move alternatives are associated with longer decision times, whereas greater time pressure is associated with shorter decision times. All three factors are associated with lower decision quality. We discuss the findings against the predictions of different decision models in which individuals sequentially acquire information about alternatives with uncertain valuations, extending theories originally developed in the context of nonstrategic decisions to a strategic environment.
15 May 2026
Read appraisal →The New England journal of medicine
Endovascular Treatment of Medium-Vessel-Occlusion Strokes
BACKGROUND: Endovascular thrombectomy for acute ischemic stroke due to medium-vessel occlusion has had varying results across trials. Whether thrombectomy improves functional outcomes in patients with medium-vessel occlusion and moderate-to-severe deficits is unclear. METHODS: We conducted an open-label, randomized trial with blinded outcome assessment at 48 centers in China. Eligible patients were adults who presented within 24 hours after the onset of a moderate-to-severe stroke (National Institutes of Health Stroke Scale [NIHSS] score, ≥6; scale, 0 to 42, with higher scores indicating greater neurologic deficits) due to occlusion of a medium vessel. Patients were assigned in a 1:1 ratio to thrombectomy plus medical management (thrombectomy group) or medical management alone (control group). The primary outcome was functional disability as measured by the shift in the modified Rankin scale score (scale, 0 [no disability] to 6 [death]) at 90 days. Violation of the proportional-odds assumption precluded the use of shift in the modified Rankin scale score, so as prespecified, functional independence (modified Rankin scale score of 0, 1, or 2) at 90 days was used as the primary outcome. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: Among 280 patients in the thrombectomy group and 283 in the control group, the median age was 71 years, the median NIHSS score was 10 (range, 3 to 36), and 42.8% were women; 36.6% received intravenous thrombolysis. Functional independence at 90 days was seen in 58.6% of the patients in the thrombectomy group and in 46.6% of those in the control group (adjusted rate ratio, 1.24; 95% confidence interval, 1.07 to 1.44; P = 0.004). The incidence of symptomatic intracranial hemorrhage was 4.7% in the thrombectomy group and 2.2% in the control group; 90-day mortality was 11.1% and 10.2%, respectively. CONCLUSIONS: Among patients with acute ischemic stroke due to medium-vessel occlusion and moderate-to-severe deficits, thrombectomy led to a greater likelihood of functional independence than medical management alone but also to a higher risk of symptomatic intracranial hemorrhage. (Funded by the National Natural Science Foundation of China and the Noncommunicable Chronic Diseases-National Science and Technology Major Project; ORIENTAL-MeVO ClinicalTrials.gov number, NCT06146790.).
15 May 2026
Read appraisal →Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
Thrombolysis in spinal cord infarction: Case report and systematic review
INTRODUCTION: Spinal cord infarction (SCI) is a rare but severe cause of acute myelopathy, and evidence supporting reperfusion therapies remains limited. METHODS: We report a 73-year-old man with spontaneous cervical SCI treated with intravenous alteplase and perform a systematic review (database search from inception to 13 November 2025) of case reports/series describing intravenous (IV) or intra-arterial (IA) thrombolysis for SCI, extracting data about clinical presentation, diagnostic and therapeutic work-up and functional outcomes. RESULTS: Our patient improved after thrombolysis and achieved functional independence at 3 months (modified Rankin Scale [mRS] 2). The review identified 21 studies (19 case reports, 2 case series) totaling 25 patients; including our case, 26 patients were analyzed. Mean age was 57.4 years (range 14-83), and anterior spinal artery (ASA) syndrome was the most common presentation. Most patients received IV thrombolysis; 4 underwent IA therapy (alone or combined). Considering the last available assessment, 14/25 patients (56.0%) had a favorable outcome (mRS 0-2), 8/25 (32.0%) had mRS 3, and 3/25 (12.0%) had mRS 4-5. No symptomatic treatment-related hemorrhagic complications were reported. DISCUSSION AND CONCLUSION: Published experience suggests that thrombolysis in carefully selected patients with suspected SCI may represent a reasonably safe therapeutic option, but evidence is limited and subject to major bias. Prospective registries and multicenter studies are needed to clarify safety, efficacy, and selection criteria.
12 May 2026
Read appraisal →AJNR. American journal of neuroradiology
Neuroimaging Predictors of Futile Recanalization in Anterior Circulation Stroke: A Systematic Review and Meta-Analysis
BACKGROUND: Mechanical thrombectomy (MT) has transformed the management of large vessel occlusion stroke; however, a considerable proportion of patients fail to achieve functional recovery despite successful recanalization. This futile recanalization underscores the need to better understand imaging biomarkers that may predict poor outcomes after endovascular therapy. PURPOSE: To systematically review and synthesize evidence on neuroimaging biomarkers associated with futile recanalization after MT in acute ischemic stroke. DATA SOURCES: PubMed, Scopus, Web of Science, and EMBASE databases were searched up to March 2025, supplemented by manual reference screening. STUDY SELECTION: Eligible studies enrolled adult patients with anterior-circulation stroke who underwent thrombectomy, reported pretreatment neuroimaging findings, and evaluated functional outcomes despite successful reperfusion. Case reports, reviews, abstracts, and nonhuman studies were excluded. DATA ANALYSIS: Two reviewers independently screened, extracted data, and assessed study quality using the Prediction Model Risk of Bias Assessment Tool. Random-effects meta-analysis was performed where appropriate. Heterogeneity, publication bias, and sensitivity analyses were undertaken. DATA SYNTHESIS: Fifty-one studies were included. Lower ASPECTS scores were strongly associated with futile recanalization (OR = 0.81). Core infarct volume showed inconsistent associations, whereas perfusion and collateral markers, including elevated hypoperfusion intensity ratio, delayed venous outflow, and poor collateral scores, demonstrated strong predictive value. Chronic white-matter injury, leukoaraiosis, and cerebral atrophy were also consistently associated with worse outcomes. LIMITATIONS: Limitations included heterogeneity in imaging protocols and thresholds; predominance of retrospective single-center cohorts; limited direct comparison across imaging modalities; and variable adjustment for confounders. CONCLUSIONS: Neuroimaging biomarkers, particularly ASPECTS, perfusion-derived metrics, collateral status, and markers of chronic small vessel disease, provide important prognostic information for identifying patients at risk of futile recanalization despite successful thrombectomy.
11 May 2026
Read appraisal →Journal of wound care
Comparison between foam dressings impregnated with ionic silver and silver sulfadiazine cream 1% in treating deep burns.
OBJECTIVE: The aim of this trial was to evaluate the effectiveness of foam dressings impregnated with ionic silver (AgF) compared to the traditional treatment of 1% silver sulfadiazine cream (SSD) in deep burns (deep dermal and full-thickness burns) and assess the cost-effectiveness ratio between the two treatments. METHOD: This was a randomised clinical trial of patients who were divided into two equal-sized treatment groups: Group 1-SSD or Group 2 - AgF. Inclusion criteria were patients aged between 18-60 years with burns of thermal origin affecting 10-30% of the body surface area, and with a comparable percentage of deep burns. The following outcomes were analysed: pain; discomfort; wound infection; need for new grafting; ease of dressing application; length of stay; and cost of treatment. RESULTS: A total of 40 patients took part (20 in each group). Regarding patients' experience of pain, data analysis revealed more effective pain control in patients treated with AgF. Additionally, the AgF dressing was considered safer, more comfortable and presented an average lower cost of 30.6% compared to the SSD. CONCLUSION: The findings of this trial showed that, compared to the SSD, the AgF dressings were more effective in treating deep burns, to prepare them for skin graft surgery.
10 May 2026
Read appraisal →The New England journal of medicine
Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults
BACKGROUND: For critically ill adults undergoing tracheal intubation, observational studies suggest that the use of etomidate to induce anesthesia may increase the risk of death. Whether the use of ketamine rather than etomidate decreases the risk of death is uncertain. METHODS: In a randomized trial conducted in 14 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults who were undergoing tracheal intubation to receive ketamine or etomidate for the induction of anesthesia. The primary outcome was in-hospital death from any cause by day 28. The secondary outcome was cardiovascular collapse during intubation, defined by the occurrence of a systolic blood pressure below 65 mm Hg, receipt of a new or increased dose of vasopressors, or cardiac arrest. RESULTS: A total of 2365 patients underwent randomization and were included in the trial population; 1176 were assigned to the ketamine group and 1189 to the etomidate group. In-hospital death by day 28 occurred in 330 of 1173 patients (28.1%) in the ketamine group and in 345 of 1186 patients (29.1%) in the etomidate group (risk difference adjusted for trial site, -0.8 percentage points; 95% confidence interval [CI], -4.5 to 2.9; P = 0.65). Cardiovascular collapse during intubation occurred in 260 of 1176 patients (22.1%) in the ketamine group and in 202 of 1189 patients (17.0%) in the etomidate group (risk difference, 5.1 percentage points; 95% CI, 1.9 to 8.3). Prespecified safety outcomes were similar in the two groups. CONCLUSIONS: Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate. (Funded by the Patient-Centered Outcomes Research Institute and others; RSI ClinicalTrials.gov number, NCT05277896.).
24 Apr 2026
Read appraisal →Inflammation research : official journal of the European Histamine Research Society ... [et al.]
The calcium-sensing receptor in sepsis and septic shock, mechanistic pathways and translational perspectives: a systematic review.
BACKGROUND: Sepsis and septic shock are major causes of mortality in critically ill patients. They are linked to widespread metabolic and immune dysregulation, including alterations in calcium and phosphate homeostasis. The calcium-sensing receptor (CaSR) not only plays a role in mineral balance, but also modulates key immune pathways and may contribute to the pathogenesis of sepsis. METHODS: A systematic literature review was conducted according to PRISMA 2020 guidelines. Four databases (PubMed, EMBASE, Cochrane Library, and Google Scholar) were searched for studies published since 1990. To be eligible for inclusion, articles had to be original research, reviews, or clinical trials involving adult models (mammalian or human). Full-text availability was required. Risk of bias was assessed for all studies included. RESULTS: Sixty-six articles met the inclusion criteria: 49 original studies and 17 reviews. No randomized controlled trials or meta-analyses were identified. Most studies relied on in vitro or in vivo models. CaSR was consistently reported to be upregulated or activated following exposure to bacterial and inflammatory stimuli in immune cells, including monocytes and lymphocytes. CaSR activation promotes proinflammatory cytokine release, notably IL-1β via the NOD like receptor family 3 (NLRP3) inflammasome although results in intestinal epithelial models remain inconsistent. In non-septic models, CaSR activation was associated with tissue and organ injury, including renal and cardiac damage, as well as vasoplegia related to endothelial dysfunction. Preclinical models of pneumonia and endotoxemia suggest that CaSR antagonists may effectively mitigate inflammation and organ injury. CONCLUSION: This systematic review identifies the CaSR as an amplifier of the host inflammatory response across both septic and non-septic preclinical models The lack of robust clinical data underscores the need for translational studies assessing CaSR expression or activity in patients with sepsis or septic shock, alongside in vivo validation of CaSR inhibition as a therapeutic strategy.
19 Apr 2026
Read appraisal →PloS one
The association between RDW-to-platelet ratio and in-hospital mortality in critically ill stroke patients: A retrospective cohort study based on the eICU database
OBJECTIVE: The red cell distribution width-to-platelet ratio (RDW-to-platelet ratio, RPR) is a potential biomarker of inflammation and bone marrow function. This study aimed to investigate the association between RPR and in-hospital mortality in critically ill stroke patients in the eICU, and to evaluate mediating role of APACHE-IV score. METHOD: This retrospective cohort study utilized data from the 2014-2015 US multicenter eICU database. Of 200,859 initially included patients, 9,736 critically ill stroke patients were analyzed after excluding non-stroke cases and those with missing key variables. Multivariable logistic regression assessed the relationship between RPR and in-hospital mortality, adjusting for age, sex, comorbidities, and laboratory parameters, with multiple imputation for missing data. Subgroup analyses, mediation analysis, and restricted cubic spline modeling were performed. RESULTS: Patients with higher RPR exhibited significantly elevated in-hospital mortality (17.7% vs. 11.6%, P < 0.001). After adjustment, each unit increase in RPR was associated with 4.6% higher odds of death (adjusted OR=1.046, 95% CI: 1.032-1.061, P < 0.001), with consistent findings across subgroups. Restricted cubic spline analysis indicated a linear relationship. Mediation analysis showed that APACHE-IV score mediated 20.15% of the total effect (P < 0.001). CONCLUSIONS: Elevated RPR is independently associated in-hospital mortality in critically ill stroke patients, partly mediated by disease severity. As a simple and accessible marker, RPR shows promise for clinical prognostic risk stratification.
18 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Stroke thrombectomy with a novel reperfusion system including a 0.088'' aspiration catheter: the Imperative Trial
BACKGROUND: Mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) stroke, yet most device trials focus on individual technologies rather than complete systems. OBJECTIVE: To evaluate the safety and efficacy of the Zoom Reperfusion System compared with performance goals derived from a meta-analysis of trials using established thrombectomy technologies. METHODS: Prospective, multicenter, non-randomized, investigational device exemption trial conducted across 26 United States centers from October 2021 to March 2024. Adults with anterior circulation LVO stroke within 8 hours of onset were treated using the Zoom System, which includes aspiration catheters ranging from 0.035″ to 0.071″, and a novel 0.088″ intracranial guide/aspiration catheter. The primary efficacy endpoint was successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3) within three passes using Zoom-only components, adjudicated by an independent core laboratory. The primary safety endpoint was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included final reperfusion, first-pass success, time to reperfusion, 90-day modified Rankin Scale (mRS), and mortality. RESULTS: Among 260 patients (median age 68 years; median National Institutes of Health Stroke Scale (NIHSS) 15), successful reperfusion within three passes was achieved in 83% (216/259; 95% CI: 78% to 89%), exceeding the performance goal (p<0.001). Final reperfusion was 92%, with 5.5% requiring rescue devices. First-pass mTICI 2b-3 success was 57%. Median puncture-to-reperfusion time was 19 min. At 90 days, 55% achieved mRS 0-2. The sICH rate was 1.9%, and 90-day mortality was 12.7%. CONCLUSIONS: The Zoom Reperfusion System demonstrated a safety and efficacy profile exceeding prespecified contemporary performance metrics with potential to significantly shorten reperfusion times and reduce the need for rescue therapy. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov--Identifier:NCT04129125.
17 Apr 2026
Read appraisal →Neurology
Systolic Blood Pressure Trajectory and Outcomes in Acute Intracerebral Hemorrhage: Pooled Analysis of the 4 INTERACT and ATACH-II Clinical Trials
BACKGROUND AND OBJECTIVES: While moderate and rapid systolic blood pressure (SBP) lowering was associated with better functional outcomes after intracerebral hemorrhage (ICH), large reductions in SBP within 1 hour, for example, reductions from >200 to <140 mm Hg, diminished or even reversed these beneficial effects. We aimed to define the optimal trajectory of SBP control in relation to favorable functional outcomes after acute ICH. METHODS: We conducted a pooled analysis of individual patient-level data from all 4 Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) and second Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II) trials, which were international, randomized, open-label, blinded, end point-assessed, controlled trials that determined the effectiveness of early intensive SBP control in acute ICH. Latent class analysis grouped SBP trajectories over the first 24 hours (9 measurements) into defined clusters. The primary outcome was functional recovery at 90 days after randomization, defined as modified Rankin Scale (mRS) scores of 3-6. Logistic regression models with adjustment for baseline covariates and trial were used to determine associations between SBP cluster trajectories and outcomes in INTERACT, with validation in ATACH-II. RESULTS: A total of 11,269 patients (INTERACT n = 10,269; ATACH-II n = 1,000; mean age 62.4 years; female 36.4%) with at least 1 postrandomization SBP reading were included. Six SBP trajectories were identified: low, moderate-to-low, moderate, high, high-to-moderate, and high-to-low. Compared with the low SBP group, associations with poor functional outcome (mRS scores 3-6) increased progressively across other groups in INTERACT (p = 0.04 for trend). Adjusted odds ratios (95% CI) for groups 2 to 6 were 1.16 (0.98-1.37), 1.44 (1.18-1.75), 1.46 (1.15-1.87), 1.90 (1.32-2.73), and 1.28 (1.02-1.60), respectively. A similar albeit nonsignificant trend was observed in ATACH-II due to limited power. DISCUSSION: Distinct SBP trajectories over 24 hours defined prognosis after ICH, with a severe hypertensive group having the highest odds of death or disability, regardless of the BP-lowering strategy used. These findings highlight the importance of well-controlled but tailored SBP management strategies after ICH. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that distinct SBP trajectories over 24 hours are associated with prognosis after acute ICH, with a severe hypertensive group having the highest odds of poor functional outcome, regardless of the BP-lowering strategy used. TRIAL REGISTRATION INFORMATION: (INTERACT1 NCT00226096; INTERACT2 NCT00716079; INTERACT3 NCT03209258; INTERACT4 NCT03790800; ATACH-2 NCT01176565).
15 Apr 2026
Read appraisal →JAMA
Restrictive vs Liberal Physical Restraint Strategies in Critically Ill Patients: The R2D2-ICU Randomized Clinical Trial
IMPORTANCE: The effect of wrist-strap physical restraints on outcomes in patients receiving mechanical ventilation in the intensive care unit (ICU) remains uncertain. OBJECTIVE: To investigate the effect of a low-use wrist-strap physical restraint strategy in critically ill patients receiving invasive mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS: Open-label randomized clinical trial conducted across 10 ICUs in France. Between January 5, 2021, and January 2, 2024, 405 adult patients who had initiated invasive mechanical ventilation within the previous 6 hours and were expected to require ventilation for at least 48 hours were enrolled. Follow-up was completed on May 17, 2024. Statistical analysis was conducted from June 1, 2025, to December 15, 2025. INTERVENTIONS: Patients were randomized to undergo either a restrictive, low-use physical restraint strategy (wrist straps avoided unless necessary because of severe agitation, defined as a Richmond Agitation-Sedation Scale score of ≥3 [on a scale from -5 (unresponsive) to 4 (combative)]; n = 201) or a liberal, high-use strategy (wrist straps applied systematically and reassessed daily; n = 204). Discontinuation of restraints was allowed in patients who were awake or extubated without delirium (measured via the Confusion Assessment Method for the ICU). MAIN OUTCOMES AND MEASURES: The primary outcome was the number of days alive without coma or delirium during the first 14 days after randomization. Secondary outcomes included incidence of self-extubation and day-90 mortality. RESULTS: Among 396 patients with available primary outcome data, the median (IQR) age was 65 (56-73) years, 245 (62%) were male, and the median (IQR) Sequential Organ Failure Assessment score was 7 (4-10). The mean days alive without coma or delirium were 6.67 days (95% CI, 5.69-7.65) in the low-use strategy group and 6.30 days (95% CI, 5.35-7.24) in the high-use strategy group (adjusted mean difference, 0.37 days [95% CI, -0.71 to 1.46]; P = .51). Self-extubation occurred in 18 patients (9.2%) in the low-use strategy group and 17 (8.5%) in the high-use strategy group, and day-90 mortality was 37.2% and 41.0%, respectively. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, among adult patients receiving mechanical ventilation in the ICU, a low-use wrist-strap physical restraint strategy compared with a high-use strategy did not reduce days free of delirium or coma at 14 days. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04273360.
15 Apr 2026
Read appraisal →Games for health journal
The Effect of Emergency Escape Room Simulation on Knowledge, Anxiety, and Satisfaction Levels of Students: A Randomized Controlled Trial
BACKGROUND: The aim of this study is to determine the effect of escape room simulation intervention on the knowledge, anxiety, and satisfaction levels of students in emergency nursing education. METHODS: This randomized controlled study was conducted with 40 students studying at the nursing faculty of a university in Istanbul. The students in the intervention group (n = 20) were given an escape room simulation intervention related to emergency nursing education. The students in the control group (n = 20) were not given any intervention other than the traditional education method. Data were collected using the Knowledge Test, State Anxiety Scale, and Visual Analog Scale for satisfaction. RESULTS: The knowledge level of the students in the intervention group measured immediately after the education (P = 0.003), 1 week after the education (P < 0.001), and 1 month after the education (P < 0.001) was found to be significantly higher than that of the control group. While no significant difference was found in anxiety levels before and after the education between the groups, a significant difference was found in anxiety levels before and after the training in the intervention group (P < 0.001). The satisfaction level measured immediately after the education was found to be significantly higher in the intervention group than in the control group (P < 0.001). CONCLUSION: This study show that escape room simulation increased emergency nursing knowledge and satisfaction and reduced anxiety levels of the students. It is recommended that escape room simulation intervention be used in more studies in nursing education. The study was registered on ClinicalTrials.gov.tr with the number NCT06619119.
11 Apr 2026
Read appraisal →BMJ (Clinical research ed.)
Non-drug perioperative interventions to reduce postoperative pulmonary complications after abdominal surgery: systematic review and meta-analysis
OBJECTIVE: To evaluate the effectiveness of perioperative non-drug interventions in reducing postoperative pulmonary complications (PPCs) in adults undergoing abdominal surgery. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Ovid MEDLINE, Embase, and Web of Science from database inception to January 2025 and updated in January 2026, with no language restrictions. STUDY SELECTION: Randomised controlled trials assessing the effectiveness of perioperative non-drug interventions for the prevention of PPCs in adults undergoing elective abdominal surgery under general anaesthesia, with clearly defined PPCs. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients developing PPCs. Secondary outcomes included the proportion of patients with PPC subtypes according to European Perioperative Clinical Outcome definitions (respiratory infection, respiratory failure, pleural effusion, atelectasis, or pneumothorax) and hospital length of stay. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened studies, extracted data, and assessed risk of bias with the Cochrane RoB 2.0 tool. Data were synthesised using meta-analyses and trial sequential analyses, with the evidence certainty assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: 255 trials including 55 260 participants were included, evaluating 10 types of interventions with 39 subtypes for PPC prevention. PPCs occurred in 6467 (11.7%) participants across all included trials. High certainty evidence showed that low fraction of inspired oxygen (FiO2) significantly reduced PPCs (risk ratio 0.81, 95% confidence interval 0.71 to 0.92). Moderate certainty evidence showed benefit for four intervention types: lung protective ventilation (risk ratio 0.66, 0.57 to 0.76), physiotherapy (0.55, 0.46 to 0.65), analgesia (0.73, 0.64 to 0.84), and nutrition (0.74, 0.63 to 0.87), with individualised positive end expiratory pressure, composite lung protective ventilation, early mobilisation, and epidural analgesia also showing benefit at the subtype level. Trial sequential analysis confirmed sufficient cumulative evidence for all the above interventions except early mobilisation. By contrast, goal directed haemodynamic therapy, targeted blood pressure management, restrictive fluid therapy, and postoperative bi-level positive airway pressure showed no evidence of benefit, with moderate certainty. CONCLUSIONS: This synthesis establishes an evidence hierarchy for PPC prevention in abdominal surgery. Low FiO2 is the only intervention supported by high certainty evidence and should be prioritised in clinical practice. Other beneficial strategies include lung protective ventilation, physiotherapy, analgesic techniques, and nutrition interventions. Conversely, the role of goal directed haemodynamic therapy-despite its widespread use-warrants reconsideration for PPC prevention. These findings facilitate prioritisation of effective interventions and development of evidence based guidelines. STUDY REGISTRATION: PROSPERO CRD42025637449.
11 Apr 2026
Read appraisal →Scientific reports
Association between estimated plasma volume status and all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: analysis of the MIMIC-IV database
BACKGROUND: The estimated plasma volume status (ePVS) is an independent risk factor for poor prognosis in certain cardiovascular disease populations. However, the relationship between ePVS and prognosis in critically ill patients with non-traumatic subarachnoid hemorrhage (NSAH) remains unclear. This study aims to explore the association between ePVS and all-cause mortality (ACM) in NSAH patients. METHODS: A total of 750 NSAH patients were included in this retrospective study. The primary outcome was 1-month ACM. A Cox proportional hazards model was constructed to examine the relationship between ePVS and ACM in critically ill NSAH patients. A restricted cubic spline model was used to assess the relationship between ePVS and the outcome. RESULTS: In this patient cohort, 1-month, 3-month, and 1-year ACM rates were 21%, 25%, and 29%, respectively. After adjusting for potential confounders, we found a U-shaped relationship between ePVS and 1-month ACM, with an inflection point at 3.94. Specifically, when ePVS is below the inflection point, each unit increase in ePVS reduces the mortality risk by 56% [HR, 0.44 (95% CI 0.25, 0.76)]. However, once the inflection point is surpassed, each unit increase in ePVS increases the mortality risk by 1.8 times [HR, 2.80 (95% CI 1.58, 4.97)]. CONCLUSION: We identified a U-shaped relationship between ePVS and ACM in critically ill patients with NSAH, suggesting both low and high ePVS levels may portend adverse outcomes. Prospective multicenter studies are warranted to validate these findings and elucidate underlying mechanisms.
10 Apr 2026
Read appraisal →Journal of special operations medicine : a peer reviewed journal for SOF medical professionals
AI-Assisted Lung Sliding Detection in Point-of-Care Ultrasound by Marine Corps Corpsmen: A Multi-Reader Study
BACKGROUND: Artificial intelligence (AI) has the potential to address training limitations and inter-operator variability that constrain the use of lung ultrasound (LUS) in austere and prehospital settings. This pilot study evaluated whether AI-based decision support could improve the diagnostic accuracy and confidence of United States Marine Corps Corpsmen in identifying absent lung sliding, a key indicator of pneumothorax, during LUS interpretation. METHODS: This pilot-prospective multi-reader, multi-case study involved five military medics, all novices in point-of-care ultrasound, each interpreting 50 de-identified LUS video clips twice, once without AI assistance (control) and once with AI assistance (ATLAS, Deep Breathe Inc., London, Canada), in randomized order with at least a 2-hour washout between sessions. Expert consensus served as a reference standard. Diagnostic performance was assessed using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and accuracy. Differences were analyzed using the Random-Reader Random-Case method. Per-clip reader confidence ratings were compared using the Stuart-Maxwell test. RESULTS: AI assistance significantly improved diagnostic performance across all measured outcomes. The mean AUROC increased from 0.72 (SD 0.16) without AI to 0.93 (SD 0.04) with AI (P=.03). Sensitivity rose from 0.63 (SD 0.14) to 0.90 (SD 0.09), specificity from 0.70 (SD 0.15) to 0.86 (SD 0.10), and overall accuracy from 0.67 (SD 0.10) to 0.88 (0.06) (McNemar's test, P<.001). Reader confidence also improved, with high-confidence ratings nearly doubling from 20% to 37%, and low-confidence ratings decreasing from 38% to 33%. These distributional changes were statistically significant (Stuart-Maxwell χ², P<.001). CONCLUSION: AI support markedly improved the diagnostic accuracy and confidence of novice LUS interpretation for detecting absent lung sliding. These findings suggest that real-time AI-based decision support may help improve access to high-quality LUS in military and other resource-limited care settings.
5 Apr 2026
Read appraisal →Intensive Care Med
Critical care management of the patient with pharmaceutical poisoning
Poisonings account for up to 10% of admissions to intensive care units and represent a common yet complex challenge in critical care. While most patients recover with supportive care alone, a significant proportion require targeted interventions and advanced organ support. This state-of-the-art review provides a practical, evidence-based guide to manage pharmaceutical poisoning in the intensive care unit, with emphasis on real-world applicability for intensivists. It highlights toxicant-specific considerations for early resuscitation, structured by the ABCDE approach. Essential principles of the diagnostic workup are also summarized. In addition, the review offers actionable guidance on when and how to escalate care, moving from supportive measures to specific interventions including gastrointestinal decontamination, extracorporeal toxicant elimination, antidote therapy, and rescue strategies such as intravenous lipid emulsion and extracorporeal membrane oxygenation. Key algorithms and decision pathways-such as the diagnostic evaluation, ABCDE-based stabilization, gastrointestinal decontamination, and extracorporeal elimination approaches-are presented with visually structured figures. A comprehensive table provides an overview of the most relevant antidotes used in critical care, including indications and dosing.
1 Dec 2025
Read appraisal →Adv Anesth
The Current Use of Artificial Intelligence in Anesthesiology
Artificial intelligence (AI) applications are increasingly being used in areas of medicine such as radiology. However, within anesthesiology, there is not widespread use of AI applications at this time, though it has the potential to have a profound impact. Many applications of AI, including machine learning, deep learning, and natural language processing, are being used to create applications to enhance patient monitoring, optimize drug administration, improve decision-making, and predict postoperative complications.
1 Dec 2025
Read appraisal →Intensive Care Med
Invasive candidiasis in intensive care medicine: shaping the future of diagnosis and therapy
BACKGROUND: Invasive candidiasis (IC) remains one of the most challenging infections in critical care, contributing significantly to morbidity, prolonged organ support, and mortality among intensive care unit (ICU) patients. The clinical landscape of IC is evolving, with increasing recognition of Candida non-albicans species and other yeasts formerly classified as Candida spp., alongside emerging multidrug resistance and growing complexity in host immune profiles. OBJECTIVES: This contemporary, multidisciplinary narrative review-authored by intensivists, infectious diseases specialists, clinical microbiologists, and pharmacologists-aims to provide ICU clinicians with practical, up-to-date insights into the diagnosis and management of IC. To maintain clinical focus, the review excludes non-IC fungal infections and non-ICU patient populations. METHODS: Relevant literature and expert consensus were critically reviewed to summarize current diagnostic and therapeutic approaches for IC in critically ill patients. Emphasis was placed on pragmatic clinical application, diagnostic limitations, antifungal stewardship, and personalized therapeutic decision-making. RESULTS: Despite the availability of novel antifungal agents with improved pharmacokinetic properties, treatment success in IC depends equally on timely and accurate diagnosis and individualized, context-aware therapy. Blood cultures continue to demonstrate limited sensitivity (~40%). Non-culture assays, including β-D-glucan and molecular diagnostics, provide faster detection and high negative predictive value but suffer from low positive predictive value and inconsistent adoption in clinical practice. The absence of validated host-derived biomarkers further limits risk stratification, antifungal discontinuation decisions, and personalized care. CONCLUSIONS: Emerging antifungal agents, stewardship strategies, and multidisciplinary care models are essential to improve clinical outcomes and reduce antifungal resistance. This review underscores the need for integrated, team-based diagnostic and therapeutic approaches to close persistent gaps in IC management, ultimately promoting more effective, timely, and individualized care for critically ill patients with Candida spp.
1 Nov 2025
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