Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 107 appraisals
Journal of the American Medical Informatics Association : JAMIA
Explainable machine learning in healthcare: methods, interpretation, and applications for clinical research
OBJECTIVES: To provide a practical and methodologically grounded overview of explainable machine learning (XML) approaches in healthcare, with emphasis on their interpretation and application in clinical research and decision support. By moving beyond traditional predictive models, this primer aims to foster trust, transparency, and informed clinical decision-making, ultimately bridging the gap between data science and medical practice. MATERIALS AND METHODS: We present a structured review of commonly used XML methodologies, including global and local interpretability tools such as SHapley Additive exPlanations (SHAP), Local Interpretable Model-Agnostic Explanations (LIME), Partial Dependence Plots (PDP), and Individual Conditional Expectation (ICE) plots. For each method, we explain the underlying mechanism at a high level, visualize representative outputs, and provide structured guidance on interpretation, appropriate use, and limitations, illustrated using the publicly available Heart Disease dataset. RESULTS: XML techniques provided intuitive visual and quantitative insights into how predictors influence model predictions. Global methods characterized population-level feature effects, whereas local methods revealed patient-level contributions useful for individualized interpretation. Our worked examples demonstrate how XML outputs can identify nonlinear relationships, detect interaction effects, and reveal heterogeneity in predicted risk across patients, addressing key challenges in translating ML predictions into interpretable outputs for clinical research. DISCUSSION AND CONCLUSION: XML tools offer valuable interpretability for ML models and support more transparent and accountable ML applications in clinical research. By providing a methodologically grounded overview alongside practical implementation examples and structured guidance on each method's strengths and limitations, this primer helps bridge the gap between advanced ML methodology and clinical applicability. Thoughtful adoption of XML approaches may facilitate better understanding, communication, and critical evaluation of ML predictions in healthcare research, ultimately supporting evidence-based clinical decision-making.
2 Aug 2026
Read appraisal →Neurosurgical review
Development and external validation of a machine learning model for predicting postoperative hydrocephalus in 1,073 posterior fossa tumor patients
Postoperative hydrocephalus is a common complication following posterior fossa tumor resection, affecting 7-40% of patients. Although preoperative cerebrospinal fluid (CSF) diversion may be required in selected patients with hydrocephalus, decisions remain individualized in routine neurosurgical practice. We therefore developed and externally validated a model to provide supplementary preoperative risk stratification using routinely available variables. We retrospectively analyzed 1,073 patients following resection of posterior fossa tumors (PFTs) treated at five tertiary centers between 2013 and 2024, dividing them into a development cohort (n = 854) and an external validation cohort (n = 219). We initially screened 30 perioperative variables from the multicenter dataset and then selected a clinically implementable model restricted to variables available before tumor resection. Feature importance was ranked using Shapley additive explanations (SHAP), and seven distinct machine learning (ML) algorithms were evaluated. Model performance was comprehensively measured using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision-recall curves, and decision curve analysis. The final clinically implementable model included three preoperative variables: Evans index, tumor-fourth ventricle relationship, and preoperative cerebrospinal fluid diversion status. In the external validation cohort, the support vector machine model showed good external discrimination, with an area under the receiver operating characteristic curve of 0.877, accuracy of 81.3%, sensitivity of 80.8%, and specificity of 81.7%. Logistic regression achieved comparable discrimination. Calibration assessment suggested dataset shift between the development and external validation cohorts, indicating that absolute predicted probabilities should be interpreted cautiously in populations with different baseline risks. A concise three-variable preoperative model showed good external discrimination for clinically relevant postoperative hydrocephalus after posterior fossa tumor resection. The model may support preoperative risk communication and postoperative surveillance planning, but should not be used as a stand-alone indication for cerebrospinal fluid diversion. Prospective validation and local recalibration are warranted before routine clinical implementation.
31 July 2026
Read appraisal →JAMA
Prone Positioning in Infants With Acute Bronchiolitis: The PROPOSITIS Randomized Clinical Trial
IMPORTANCE: Prone positioning has been shown to improve respiratory mechanics and oxygenation, but its clinical benefit in infants with acute viral bronchiolitis receiving high-flow nasal cannula (HFNC) support remains unknown. OBJECTIVE: To investigate whether prone positioning in infants with moderate to severe acute bronchiolitis and HFNC support reduces escalation to noninvasive or invasive ventilation. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, open-label trial conducted in 15 pediatric intermediate or intensive care units in France. Infants aged 6 months or younger admitted for 24 hours or less with a diagnosis of acute bronchiolitis with moderate to severe respiratory distress requiring HFNC support were enrolled between January 2021 and November 2023 and followed up until hospital discharge (last patient discharged on December 11, 2023). INTERVENTIONS: Participants were randomly assigned to the prone position (n = 221) or supine position (n = 230). Infants in the prone position group received prone positioning for 24 hours or longer during the first 48 hours. All participants received standardized HFNC support at 2 L/kg/min. MAIN OUTCOMES AND MEASURES: The primary outcome was the need for escalation of care to noninvasive or invasive ventilation within the first 72 hours, according to prespecified criteria. Secondary outcomes included treatment failure, determined by an independent clinical adjudication committee; tolerance of prone positioning; length of hospital stay; duration of respiratory support; infant comfort; and adverse events. RESULTS: Among 451 infants randomized, 446 were included in the primary analysis (median age, 41 [IQR, 19-72] days; 54% male). Escalation of care occurred in 80 infants (17.9%), with no significant difference between the prone position (33/220 [15.0%]) and supine position (47/226 [20.8%]) groups (adjusted odds ratio, 0.66 [95% CI, 0.40-1.07]; P = .09). Secondary outcomes did not differ significantly between the 2 groups. In the safety analysis, serious adverse events occurred in 2 of 180 infants (1.1%) in the prone position group and 2 of 264 (0.8%) in the supine position group. CONCLUSIONS AND RELEVANCE: Prone positioning in infants with moderate to severe bronchiolitis receiving HFNC support did not significantly reduce escalation of care. However, the wide 95% confidence interval around the observed odds ratio suggests that this study was not definitive and further research is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03976895.
30 July 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
The association between pancreatic enzyme serum concentrations and blunt pancreatic trauma: a systematic review.
PURPOSE: Blunt pancreatic trauma is uncommon. When suspected, serum amylase and lipase are measured, but their diagnostic value remains uncertain. This systematic review evaluated the diagnostic performance of serum amylase and serum lipase in detecting blunt pancreatic trauma in adults. METHODS: MEDLINE, Embase, Scopus and Cochrane Central were searched for studies evaluating serum amylase and/or lipase in adults with blunt pancreatic trauma. Observational studies reporting diagnostic accuracy or clinical outcomes were included. Two reviewers independently screened studies and assessed risk of bias using the Newcastle-Ottawa Scale. RESULTS: Four observational studies met inclusion criteria. A total of 4937 patients with blunt abdominal trauma, including 150 with pancreatic injury were investigated. Two studies evaluated serum lipase alone and two compared amylase and lipase. Pancreatic injuries were graded according to the American or Japanese Association for the Surgery of Trauma. Early serum amylase measurement (< 90 min post-injury) demonstrated low sensitivity. In contrast, testing performed more than 3 h after injury has shown improved diagnostic accuracy with one study suggesting combined serum amylase and lipase testing can achieve a sensitivity of 85% and specificity of 100%. CONCLUSION: Early serum pancreatic enzymes measurement does not appear to aid initial management decisions following blunt abdominal trauma. Delayed testing (> 3-6 h), particularly using lipase or combined lipase and amylase showed improved diagnostic performance. Prospective multicentre validation is needed to define their role in guiding further imaging after equivocal or negative initial CT.
22 July 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
Fasciotens® for abdominal wall closure: current evidence and clinical perspectives.
PURPOSE: Management of open abdomen (OA) and complex ventral hernias remains associated with high morbidity, prolonged hospitalization, and substantial healthcare costs. Vertical fascial traction has emerged as a novel approach aimed at facilitating early primary fascial closure. This study provides a narrative review and multidimensional overview of the available evidence regarding the Fasciotens® device, focusing on clinical outcomes, safety, economic considerations, and organizational aspects. METHODS: A narrative systematic literature review was performed to identify studies evaluating the use of Fasciotens® in adult patients with open abdomen or complex ventral hernias. Clinical, economic, organizational, and ethical domains were assessed. RESULTS: Available evidence, primarily derived from observational studies and case series, suggests that the use of Fasciotens® is associated with high rates of primary fascial closure, shorter time to closure, and reductions in intra‑abdominal pressure. Device‑related adverse events appear to be infrequent and mainly limited to minor skin‑related complications. Preliminary economic considerations indicate that earlier closure and avoidance of complex reconstructive procedures may reduce operative time, intensive care unit stay, and overall hospital resource utilization. CONCLUSION: Current evidence supports the clinical feasibility and potential value of Fasciotens® as an adjunctive technology for the management of open abdomen and complex ventral hernias. However, the available data are limited by small sample sizes and non‑comparative study designs. Further prospective and comparative studies are needed to better define its role within standardized treatment pathways.
16 July 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
Initial surgical management of injuries to the upper extremities for patients with multiple and/or severe injuries - a systematic review and clinical practice guideline update.
PURPOSE: Our objective was to update the evidence-based and consensus-based recommendations for the initial surgical management of upper extremity injuries in patients with suspected multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2025 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to September 2024. Further literature reports were obtained from clinical experts. Randomised controlled trials (RCTs) or observational studies reporting risk-adjusted outcomes were included if they compared early versus delayed surgical treatment for fractures, vascular injuries, or nerve injuries affecting the upper extremities in patients with multiple and/or severe injuries. Studies comparing limb salvage versus amputation or comparing amputation criteria for the upper extremities were also included. We considered patient-relevant outcomes such as mortality and limb salvage, as well as the sensitivity and specificity of scores for predicting upper extremity amputation. Risk of bias was assessed at the outcome level using ROBINS-I for observational studies and AMSTAR-2 for systematic reviews. We used available meta-analyses if possible; alternatively, we synthesised the evidence narratively. We used GRADE to rate the certainty of evidence. Expert consensus was used to develop recommendations and determine their strength. RESULTS: Among 2498 records screened for eligibility, four studies were included. Observational studies addressed the timing of humeral fixation, the timing of revascularisation, or compared limb salvage with amputation. A systematic review evaluated scoring systems for mangled upper limb salvage. Four recommendations were modified, and one consensus-based recommendation was added. All five recommendations achieved strong consensus. CONCLUSION: The timing of surgical intervention for upper extremity injuries in polytrauma patients should be individualized, based on the patient's physiological status, injury pattern, and the risks and benefits of early versus delayed surgery. Although early surgery may improve functional outcomes and reduce complications, adequate patient stabilization is essential before proceeding. Limb salvage should be attempted for patients with a MESS score of less than seven, provided the patient is sufficiently stable and depending on the condition of the amputated limb.Although the guideline addresses patients with multiple and/or severe injuries, the scarce evidence, heterogeneity of the included studies and the limited representation of true polytrauma cohorts may restrict the applicability of the findings to the broader critically injured trauma population.
10 July 2026
Read appraisal →JMIR research protocols
Evaluation and Comparison of Latent Health Risk Prediction Models for Clinical Triage: Protocol for a Mixed Methods Study
BACKGROUND: Clinical triage requires integrating multiple information sources to identify patients at risk of deterioration. Tools capturing global health assessments beyond disease-specific scores are being developed using either bottom-up aggregation of simple indicators or top-down machine learning from large datasets. Their alignment with expert clinical judgment remains poorly characterized. OBJECTIVE: This study evaluates 2 latent health measurement approaches: Frailty Index-laboratory, a transparent bottom-up tool aggregating laboratory abnormalities via deficit accumulation theory, and ETHOS-ARES (Enhanced Transformer for Health Outcome Simulation-Adaptive Risk Estimation System), a transformer-based foundation model generating multidimensional patient representations from electronic health records. We assess whether each tool's severity rankings align with clinical consensus and whether they offer utility in triage decisions. METHODS: In this 3-phase mixed methods study, at least 30 clinicians across hospital specialties reviewed 20 emergency department presentations derived from Medical Information Mart for Intensive Care IV-Emergency Department. Phase 1 compared unaided clinician severity and urgency judgments against model outputs using Spearman rank correlation, with a Turing-inspired indistinguishability test assessing whether model rankings fell within the distribution of clinician assessments. Phase 2 allocated clinicians to receive Frailty Index-laboratory or ETHOS-ARES outputs, measuring anchoring effects via within-person pre-post comparisons and exploring clinical utility through semistructured interviews analyzed using the Framework Method. RESULTS: Ethics approval was granted in June 2025 (KCL Research Ethics Office; MRSP-24/25-48707). Recruitment began in October 2025 (32 clinicians recruited as of manuscript submission), with data collection expected to be completed in January 2026 and analysis planned for March or April 2026. CONCLUSIONS: This study will quantify model-clinician agreement, measure anchoring effects, and generate qualitative insights on utility, trust, and adoption. The findings will inform the implementation of latent health measurement tools in clinical practice and provide a framework for the early-stage evaluation of artificial intelligence-based clinical decision support systems.
5 July 2026
Read appraisal →Medical science monitor : international medical journal of experimental and clinical research
Advances in Remote Monitoring Technology Applications in Anesthesia: A Narrative Review
The swift progress of digital and sensor technologies is hastening the incorporation of remote monitoring into anesthesiology. While several reviews have explored telemedicine and artificial intelligence in anesthesia, most existing summaries either focus on conceptual outlook or lack systematic comparison of technical platforms and original clinical validation data. The present review provides a comprehensive, clinically oriented synthesis of remote monitoring in anesthesia, with clear focuses on technical principles, perioperative applications, platform comparisons, and evidence-based clinical outcomes. We critically assess clinical advantages and implementation hurdles, covering the full perioperative pathway - preoperative evaluation, intraoperative observation, and postoperative recovery. A head-to-head comparison of fifth generation of cellular network technology (5G), the Internet of Things (IoT), and cloud computing platforms is presented to clarify their infrastructure demands and suitability for real-world clinical scenarios. Notably, this review summarizes available clinical evidence, including evidence from the Trial of Remote Continuous versus Intermittent National Early Warning Score Monitoring after major surgery (TRaCINg) - a feasibility randomized controlled trial whose exploratory findings suggest that continuous remote monitoring may reduce unplanned intensive care unit admissions, shorten hospital stays, and facilitate earlier detection of postoperative complications. We further propose innovative solutions including multimodal data fusion and federated learning-driven predictive analytics to overcome current limitations in data interoperability, security, and clinical effectiveness. Accordingly, this paper synthesizes the latest advances in remote monitoring technology in anesthesia, clarifies its unique value relative to existing reviews, and provides practical guidance for clinical translation and future research.
2 July 2026
Read appraisal →IEEE transactions on bio-medical engineering
EMI Cancellation for Shielding-Free Ultra-Low-Field MRI
OBJECTIVE: Ultra-Low-Field Magnetic Resonance Imaging (ULF MRI) offers low cost and portability but suffers from electromagnetic interference (EMI) in unshielded environments. This study developed a deep learning-based active EMI suppression method to overcome these limitations. METHODS: Using a 68mT ULF MRI system, human body coupling was identified as a primary EMI pathway. We proposed EMIC-Net, a U-Net architecture incorporating Transformer and hybrid attention mechanisms, to learn the data-driven nonlinear mapping from sensing coil signals to radio-frequency (RF) receiver coil interference. Acquired data underwent phase and gain compensation prior to model training. The model's efficacy was validated through in vivo human brain imaging, comparing its performance with EDITER and standard CNN methods, and by assessing the impact of varying EMI coil numbers and training data volumes. RESULTS: EMIC-Net effectively suppressed complex dynamic EMI. It restored image SNR from 2.35 dB to 17.63 dB, with significant PSNR and SSIM improvements. Image quality neared shielded acquisitions and surpassed comparative methods. Three EMI coils provided optimal balance, and the model showed data efficiency, requiring a small dataset for effective training. CONCLUSION: The EMIC-Net method accurately predicts and efficiently removes EMI in unshielded ULF MRI, offering superior performance and practicality. SIGNIFICANCE: This research promotes portable, low-cost ULF MRI for primary healthcare and bedside diagnosis. It also offers insights for mitigating complex EMI issues in other RF sensing domains.
2 July 2026
Read appraisal →Medicine
Machine learning models to predict ICU admission of patients with COPD and depression: A retrospective cohort study
This study aimed to develop and validate a machine learning (ML)-based predictive model to identify risk factors associated with intensive care unit (ICU) admission among patients with comorbid Chronic Obstructive Pulmonary Disease (COPD) and depression. Data of patients diagnosed with both COPD and depression were extracted from the MIMIC-IV version 3.1 database. A total of 1121 patients with first-time hospitalization and comorbid COPD and depression were included. Feature selection was performed using the Boruta algorithm. Five ML algorithms were employed to construct prediction models. Model performance was evaluated using the receiver operating characteristic curve, area under the curve, calibration curves, and decision curve analysis. Shapley additive explanations (SHAP) plots were used to interpret the contribution of each feature to the model's predictions. Sixteen variables identified by the Boruta algorithm were used to build the predictive models, including chloride, prothrombin time, phosphorus, bicarbonate, international normalized ratio, mean corpuscular hemoglobin (MCH) concentration (MCHC), mean corpuscular hemoglobin, hemoglobin, hematocrit (HCT), total calcium, paraplegia, cerebrovascular disease, smoker status, invasivevent, sepsis, and acute kidney injury (AKI). The Random Forest model performed the best: specificity (0.948), positive predictive value (0.924), precision (0.924), F1 score (0.887), balanced accuracy (0.901), sensitivity (0.853), negative predictive value (0.898), and recall (0.853). SHAP analysis indicated that AKI (0.212), sepsis (0.092), and invasivevent (0.073) were the most influential predictors, followed by anemia-related features such as hemoglobin (0.023), HCT (0.023), and MCHC (0.022). ML analysis revealed that AKI, sepsis, invasivevent, and anemia-related indicators are key risk factors for ICU admission among COPD patients with depression. However, it is important to note that the findings lack external validation, which warrants further investigation in diverse patient populations.
29 June 2026
Read appraisal →Prehospital and disaster medicine
Non-Resuscitative Telecommunicator-Assisted First Aid: A Scoping Review
INTRODUCTION: The provision of instant telephone pre-arrival instructions (PAI) on first aid to laypeople by emergency services' telecommunicators for conditions beyond cardiac arrest, such as trauma or acute coronary syndrome, is practiced by emergency services around the world and is recognized by some prehospital systems as a standard of care. However, to the best of the authors' knowledge, no attempts have been made to date to systematically summarize the related research evidence. STUDY OBJECTIVE: The aim of this study was to systematically map and analyze published quantitative research on telecommunicator-assisted first aid (TAFA) for medical emergencies other than cardiac arrest. METHODS: Peer-reviewed journal papers reporting original quantitative data on experimental or real-world applications of TAFA were identified through PubMed, Scopus, and Google Scholar. Studies focusing solely on cardiac arrest management (cardiopulmonary resuscitation [CPR] or automated external defibrillation) were excluded. A scoping review of eligible papers was conducted in accordance with the PRISMA-ScR guidance. RESULTS: Twenty-two studies published from 2000 through 2024 met inclusion criteria. First authors represented nine high-income countries. The studies investigated hypothetical or actual application of TAFA for anaphylaxis, chest pain or myocardial infarction, stroke, trauma, bleeding, childbirth, foreign body airway obstruction, opioid overdose, and respiratory arrest; four studies did not specify the type of emergency. Eight studies (36.4%) analyzed real Emergency Medical Services (EMS) call data, another eight (36.4%) were simulation-based, five (22.7%) used surveys, and one (4.5%) represented a cost-effectiveness analysis. The studies described existing TAFA practices, evaluated expectations and perceptions of the service by the public, demonstrated the feasibility of experimental techniques, including video communication, and identified areas for future investigations and interventions. Along with some beneficial effects of TAFA, several studies have demonstrated downsides of the practice, including suboptimal dispatcher adherence to pre-arrival protocols. The relationships between the real-world application of TAFA and patient outcomes are unclear. CONCLUSION: According to the review of quantitative research, non-resuscitative TAFA remains an under-explored area of prehospital medicine. Considering the paucity and the inconclusiveness of available evidence, significantly more research is required to better understand its effects and practical implications. The evidence map generated by this scoping review may assist the professional community in advancing the development of non-resuscitative TAFA.
26 June 2026
Read appraisal →Critical care (London, England)
Large language models for optimizing clinical trial recruitment in ICUs: application to ventilator-induced diaphragm dysfunction
BACKGROUND: Ventilator-induced diaphragm dysfunction (VIDD) is a frequent and under-recognized consequence of prolonged mechanical ventilation in intensive-care unit (ICU) patients. Identifying eligible candidates for clinical trials targeting VIDD remains a major operational challenge. This study evaluates the use of large language models (LLMs) to automate patient prescreening from ICU discharge summaries and estimate recruitment capacity for a future phase 2 trial. METHODS: We developed an LLM-based prescreening pipeline to assess trial eligibility criteria from ICU discharge summaries, which was deployed to screen all 2024 ICU stays. Stays that were flagged as potentially eligible underwent expert adjudication. An enriched set of 50 ICU stays was independently annotated by six clinicians to define a reference standard, which was used to evaluate criterion-level model performances using F1-scores. RESULTS: The best-performing model was GPT-OSS:120B with a criterion-level F1-score of 0.82. When applied to consecutive 1,342 ICU stays from Montpellier University Hospital in 2024, the selected model identified 532 patients with ≥ 3 days of mechanical ventilation. After applying exclusion criteria, 185 patients remained potentially eligible. Expert review confirmed 133 patients as eligible, resulting in a positive predictive value of 72% (95% CI 65-78). The LLM-assisted workflow resulted in an estimated 86% reduction in clinician review time. The LLM-based prescreening pipelines achieved criterion-level F1 scores ranging from 0.73 to 0.82, with GPT-OSS:120B demonstrating the highest performance. CONCLUSIONS: LLM-based prescreening offers a promising approach for identifying trial candidates in critical care, prioritizing candidates for clinician review. Future deployments should include targeted expert validation and ongoing monitoring to ensure safety and generalizability.
13 June 2026
Read appraisal →Neurology
Acute Kidney Injury and Risk of Adverse Neurocognitive Outcomes: A Systematic Review and Meta-Analysis
BACKGROUND AND OBJECTIVES: Chronic kidney disease is a recognized risk factor for adverse neurocognitive outcomes, but the effect of acute kidney injury (AKI) on brain health remains less well defined. We conducted a systematic review and meta-analysis to evaluate associations between AKI and subsequent risk of stroke, delirium, and dementia. METHODS: Eligible studies were identified by searching Ovid MEDLINE and Embase from inception (Ovid: January 1946; Embase: January 1970) until April 2025. Studies were included if they reported quantitative estimates with measures of precision for the association between AKI and delirium, stroke, or dementia in adult populations. Two reviewers independently screened and extracted data, and study quality was assessed using standardized criteria. Study characteristics, participant demographics, and adjusted effect estimates (hazard ratios [HRs] or odds ratios [ORs]) with 95% CIs were extracted. Pooled HRs and ORs with 95% CIs were calculated using random-effects models. Heterogeneity was evaluated with the χ2 test and I2 statistic, and sources of heterogeneity were explored through prespecified subgroup analyses and meta-regression. RESULTS: We identified 49 studies comprising 11,253,825 participants with 1,279,145 events. Individuals with AKI were at increased risk of stroke (pooled adjusted HR 1.35, 95% CI 1.20-1.52), delirium (pooled adjusted OR 1.76; 1.42-2.17), and dementia (pooled adjusted HR 1.64, 1.41-1.89). A gradient of risk across increasing AKI stages was demonstrated for stroke (stage 1: HR 1.11; 1.00-1.23; combined stages 2 and 3: HR 1.57; 1.35-1.81). AKI was also associated with higher in-hospital and 90-day mortality poststroke (pooled HR 2.13, 1.56-2.90, and 4.81, 2.55-9.08, respectively) and with 90-day disability (pooled adjusted OR 1.47, 1.22-1.76). Associations between AKI and all outcomes were directionally consistent across sensitivity analyses and pooled propensity score-matched studies. DISCUSSION: In this systematic review and meta-analysis, AKI was consistently associated with increased short-term and long-term neurocognitive risk, including stroke, delirium, and dementia. These findings suggest that AKI may identify individuals vulnerable to both acute and chronic brain injury. Further studies are needed to clarify mechanisms linking AKI to brain injury and to identify strategies to mitigate neurocognitive risk in this high-risk population.
9 June 2026
Read appraisal →Acta microbiologica et immunologica Hungarica
Characteristics of fungaemia caused by Trichosporon species in South-Eastern Europe
The incidence of fungaemia caused by rare yeasts, particularly Trichosporon species, is rising globally, posing diagnostic and therapeutic challenges-especially in immunocompromised patients. This systematic review aims to analyse the epidemiology, diagnostic approaches, antifungal susceptibility, and clinical outcomes of Trichosporon fungaemia (TF) in South-Eastern Europe, including Turkey. A comprehensive search was conducted in PubMed and Scopus in August 2025. A total of 59 cases from 12 studies were identified, with Trichosporon asahii being the most prevalent species (86.4%). Cases originated from Turkey (79.7%), Greece (18.6%), and Croatia (1.7%). Diagnostic techniques varied, with phenotypic methods still widely used. MALDI-TOF MS and DNA sequencing were mainly applied as confirmatory methods. Haematologic disorders were the most frequently reported underlying conditions among the patients. Sixteen breakthrough fungaemia cases-occurring despite empirical or prophylactic antifungal therapy-were identified. Although rare, TF represents a severe infection with significant mortality in South-Eastern Europe. Early and accurate species identification-facilitated by advanced diagnostic tools-is crucial for effective management. In addition to diagnostic difficulties, treatment is also challenging. Voriconazole appears to be the preferred antifungal agent, even in breakthrough fungaemia cases. Enhanced awareness, routine use of molecular diagnostics, and ongoing epidemiological monitoring are essential to improve patient outcomes.
1 June 2026
Read appraisal →Neurosurgical review
Bilateral decompressive craniectomy in pediatric patients: A systematic review.
Traumatic brain injury (TBI) and other acute neurological insults remain leading causes of pediatric morbidity and mortality. In cases where elevated intracranial pressure (ICP) is refractory to maximal medical therapy, decompressive craniectomy (DC) may be considered as a salvage intervention. Although bilateral, bifrontal, bitemporal, and cruciate decompressive approaches are used in selected patients with diffuse cerebral edema or bihemispheric swelling, their role, timing, complications, and outcomes remain poorly defined in pediatric populations. Following PRISMA guidelines, PubMed, Scopus, Embase, and PubMed Central were searched for English-language studies reporting bifrontal, bitemporal, bilateral, or cruciate decompressive craniectomy in pediatric or young adult patients, defined a priori as age ≤ 21 years, with refractory intracranial hypertension from traumatic or non-traumatic etiologies. Studies were included only if the cohort met this age criterion or if pediatric/young adult outcomes could be separately extracted. Mixed-age studies without extractable pediatric/young adult data were excluded from the primary synthesis. Data regarding demographics, operative technique, timing, mortality, complications, ICP response, and functional outcomes were extracted and synthesized qualitatively because of clinical and methodological heterogeneity. Five studies met eligibility criteria for the primary pediatric/young adult synthesis, including one small randomized pilot trial and four observational cohorts. The available evidence was heterogeneous with respect to indication, ICP threshold, timing of surgery, operative technique, and outcome measurement. Bitemporal, bifrontal, bilateral, and cruciate decompressive strategies were reported primarily in selected patients with severe traumatic brain injury or diffuse cerebral swelling. Several larger pediatric decompressive craniectomy cohorts included only small bilateral or bifrontal subgroups, and outcomes were not always stratified by technique. Reported mortality, functional recovery, hydrocephalus, subgaleal collections, and need for reoperation varied across studies. Early decompression was associated with ICP reduction and favorable outcomes in limited reports, including one small randomized trial, but the evidence remains insufficient to determine comparative efficacy, optimal timing, or superiority of one bilateral decompressive approach. Bilateral, bifrontal, bitemporal, and cruciate decompressive craniectomy have been reported as feasible salvage strategies for carefully selected pediatric and young adult patients with refractory intracranial hypertension. However, current evidence is sparse, heterogeneous, and often not technique-specific. Therefore, definitive conclusions regarding efficacy, optimal timing, or superiority of one bilateral approach cannot be made. Prospective multicenter studies with standardized age definitions, ICP thresholds, operative taxonomy, complication reporting, and long-term neurocognitive outcomes are needed.
1 June 2026
Read appraisal →Critical care explorations
Linking the Virtual Pediatric System and Pediatric Hospital Information System Databases to Create Novel PICU Research Datasets
BACKGROUND: Lack of a robust, national PICU database hinders epidemiologic and quasi-experimental research of PICU care. Combining the virtual pediatric system (VPS) and pediatric health information system (PHIS) databases would overcome this data gap. However, limits on the use of variables containing protected health information (PHI) have prevented prior large-scale VPS-PHIS linkage. We sought to link VPS and PHIS records from 31 hospitals without using PHI. METHODS: We performed a database linkage study utilizing a sequential direct + probabilistic linkage approach with records from 31 hospitals contributing to VPS and PHIS for patients discharged between January 1, 2017 and December 31, 2022. Using directly linked records as a reference, we assessed the accuracy of probabilistically linked pairs with data from four hospitals by describing the percent of false-negative and false-positive links. We also compared demographic and clinical variables between linked and unlinked records using Cohen's Effect size (CES). RESULTS: We obtained 337,836 VPS and 3,515,595 PHIS records without PHI. In total, we linked 319,955 of 337,836 (94.7%) VPS records. Direct linkage contributed 274,345 of 319,955 (85.7%) of all record linkages. Probabilistic linkage contributed 45,610 of 319,955 (14.3%) of all record linkages. Assessment of the probabilistic linkage found 0.21% false-negative links and no false-positive links. We found negligible imbalance by CES for gender (% female in linked vs. unlinked: 44.8% vs. 43.6%, CES 0.024), age in years (median [interquartile range (IQR)]: 5.1 [1.21-13.22] vs. 5.53 [1.53-13.38], CES 0.054), Pediatric Risk of Mortality 3 score (median [IQR]: 0.44 [0.3-0.9] vs. 0.37 [0.29-1.02], CES 0.096), or days in PICU (median [IQR]: 1.55 [0.8-3.47] vs. 1.33 [0.79-3.45], CES 0.031). CONCLUSIONS: Using a combined direct and probabilistic linkage approach, we created a highly accurate linkage VPS and PHIS database records from 31 hospitals without using PHI. This combined database can be used to create novel datasets for PICU research.
31 May 2026
Read appraisal →Science (New York, N.Y.)
Strain-resilient intrinsically stretchable electrochemical biointerfaces
Stretchable bioelectronics promise seamless integration with dynamic tissues, yet their electrochemical performance often collapses under strain owing to cracking, interlayer delamination, and signal distortion. We introduce an intrinsically stretchable interface for resilient electrochemical sensing (SIRES) built from a strain-resilient conductor, an electrically tunable interlayer, and a stretchable functional coating. By offsetting strain-induced resistance increases with gains in active surface area, SIRES maintains near-constant resistance and high-fidelity electrochemical readouts under strains up to 300%. The platform supports voltammetric, potentiometric, and amperometric modalities and enables multiplexed molecular monitoring across dynamically deforming tissues in wearable and implantable formats. Its unified architecture provides delamination-resistant interfaces suitable for long-term use, and the design rules generalize to affinity-based transduction, establishing a pathway toward strain-resilient molecular sensing for precision diagnostics and therapy.
31 May 2026
Read appraisal →BMJ health & care informatics
Machine learning-based prediction of a high-risk kidney function trajectory class after acute kidney injury
OBJECTIVES: Monitoring kidney function after acute kidney injury (AKI) hospitalisation is essential for identifying patients at risk of rapid progression. This study developed a machine learning (ML) model to predict membership in a high-risk longitudinal estimated glomerular filtration rate (eGFR) trajectory associated with subsequent kidney replacement therapy (KRT) initiation. METHODS: We conducted a cohort study of 88 632 adults with ≥2 post-discharge eGFR measurements between 2010 and 2017. Joint latent class mixed models were used to identify dynamic eGFR trajectories from 665 499 measurements. Patient-level data splitting (80/20) was strictly enforced. Extreme gradient boosting (XGBoost) and random forest models were trained using clinical features within 3 months after discharge to predict membership in the highest-risk eGFR trajectory class. RESULTS: Three eGFR trajectories were identified: Steady Low (high-risk phenotype), Slow Decline and Recovery. The Steady Low group showed the strongest association with KRT. The 10-variable XGBoost model demonstrated excellent discrimination (AUROC 0.974, sensitivity 0.913, specificity 0.919). The eGFR slope from discharge to 3 months was the most influential predictor of high-risk progression. DISCUSSION: Although the study was limited to a single healthcare system, this ML framework identified patients at risk of rapid kidney function decline using routinely available clinical data. The model supports early risk stratification after AKI and may enable more timely kidney-protective interventions. External validation, calibration assessment and benchmarking against simpler eGFR-based rules remain important next steps. CONCLUSION: A 10-variable XGBoost model accurately identifies patients with deteriorative eGFR trajectories (Steady Low) early after discharge, providing a practical framework for personalised post-AKI kidney care.
29 May 2026
Read appraisal →The New England journal of medicine
Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism
BACKGROUND: Whether anticoagulation alone is an adequate treatment for acute, intermediate-risk pulmonary embolism is uncertain. METHODS: We conducted a multinational, adaptive-design trial with blinded outcome adjudication. Patients with intermediate-risk pulmonary embolism (with a ratio of right ventricular end-diastolic diameter to left ventricular end-diastolic diameter of ≥1.0 and an elevated troponin level) were eligible if they had at least two indicators of cardiorespiratory distress (systolic blood pressure of ≤110 mm Hg, a heart rate of ≥100 beats per minute, or a respiratory rate of >20 breaths per minute). Patients were randomly assigned to undergo ultrasound-facilitated, catheter-directed fibrinolysis with alteplase plus anticoagulation (the intervention group) or anticoagulation alone (the control group) according to prespecified treatment protocols. The primary outcome was a composite of pulmonary embolism-related death, cardiorespiratory decompensation or collapse, or symptomatic recurrence of pulmonary embolism within 7 days. RESULTS: The intention-to-treat population comprised 544 patients: 273 in the intervention group and 271 in the control group. The mean (±SD) age was 58.2±13.5 years, and 42.6% of the patients were women. A primary-outcome event occurred in 11 patients (4.0%; 95% confidence interval [CI], 2.3 to 7.1) in the intervention group and 28 (10.3%; 95% CI, 7.2 to 14.5) in the control group (relative risk, 0.39; 95% CI, 0.20 to 0.77; P = 0.005). The effect was driven primarily by a lower risk of cardiorespiratory decompensation or collapse in the intervention group. Major bleeding occurred within 7 days after randomization in 11 patients (4.1%) in the intervention group and 6 (2.2%) in the control group (P = 0.32); major bleeding occurred within 30 days in 11 patients (4.1%) and 8 patients (3.0%), respectively (P = 0.64). No substantial between-group differences in the incidence of other serious adverse events were observed up to 30 days after randomization; no intracranial hemorrhage occurred. CONCLUSIONS: In patients with acute, intermediate-risk pulmonary embolism, ultrasound-facilitated, catheter-directed fibrinolysis plus anticoagulation led to a lower risk of the composite of pulmonary embolism-related death, cardiopulmonary decompensation or collapse, or symptomatic recurrence of pulmonary embolism within 7 days than anticoagulation alone. (Funded by Boston Scientific; HI-PEITHO ClinicalTrials.gov number, NCT04790370.).
29 May 2026
Read appraisal →Scientific reports
Depressive symptoms are a key determinant of health-related quality of life in ICU survivors with psychological distress
Survivors of critical illness frequently experience persistent impairments in health-related quality of life (HRQoL), with psychological symptoms contributing substantially to this burden. The relative contribution of co-occurring depression, anxiety, and post traumatic stress symptoms remains insufficiently understood. To address this gap, we conducted a cross-sectional analysis of pre-randomization data from the PICTURE randomized controlled trial, a multicenter study of a brief primary care-based psychological intervention for post-traumatic stress disorder symptoms following critical illness, including 319 intensive care unit survivors. Clinical, demographic, and mental health assessments were obtained after ICU discharge. Latent profile analysis, random forest modeling, and quantile regression were applied to identify determinants of HRQoL measured by the EuroQol Five-Dimension Five-Level (EQ-5D-5L) index and visual analog scale (VAS). The mean EQ-5D-5L index was 0.71 (SD 0.27; median 0.81) and the mean EQ VAS score was 60.7 (SD 19.4; median 60.0), indicating considerable overall impairment. Depression, anxiety, and post-traumatic stress symptoms showed substantial overlap and formed four distinct symptom profiles associated with specific functional impairments. Screening positive for depression on the 2-item Patient Health Questionnaire (PHQ-2) with ≥ 3 points was associated with a median reduction of -0.13 (95% CI -0.19 to -0.07) on the EQ-5D-5L index and -12.45 points (95% CI -17.93 to -6.96) on the EQ VAS, exceeding clinical and demographic predictors. These findings indicate that depressive symptoms are a major determinant of impaired health related quality of life among intensive care survivors with psychological distress and support routine brief depression screening in post-intensive care follow up.Trial registration: ClinTrials.gov: NCT03315390 (Registration date: 2017-10-20); German Clinical Trials Register: DRKS-ID: DRKS00012589 (Registration date: 2017-10-17).
26 May 2026
Read appraisal →Renal failure
Development and validation of an early prediction model for bee-sting-induced acute kidney injury using machine learning
Acute kidney injury (AKI) is a severe and frequent complication following bee stings, with a reported incidence of 30-50%. Early identification is clinically challenging due to the delayed rise in serum creatinine. This retrospective study aimed to develop and validate an interpretable machine learning model for the early prediction of AKI in bee-sting patients. We included 305 patients admitted between January 2018 and September 2025, of whom 99 (32.5%) developed AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed for feature selection from 33 baseline variables, identifying eight key predictors, including lactate, creatinine, and dark urine. Six machine learning algorithms - logistic regression, random forest, support vector machine, neural network, extreme gradient boosting (XGBoost), and light gradient boosting machine - were developed and evaluated. The XGBoost model demonstrated superior performance, achieving an area under the receiver operating characteristic curve of 0.964 and an accuracy of 92.6% on the test set. SHapley Additive exPlanations analysis was applied to interpret the optimal model, highlighting creatinine, lactate dehydrogenase, lactate, and dark urine as the most influential predictors. A clinically applicable nomogram was constructed and showed good calibration and utility. In conclusion, this study successfully developed a high-performance and interpretable XGBoost model for early prediction of bee-sting-induced AKI. The validated nomogram provides an accessible bedside decision-support tool to facilitate timely risk stratification and intervention, potentially improving patient outcomes.
26 May 2026
Read appraisal →Renal failure
Complication rates of 16- and 18-gauge needles for native kidney biopsies: a systematic review and proportional meta-analysis
This systematic review and meta-analysis evaluated complication rates and diagnostic yield reported in studies of adult native kidney biopsy using 16-gauge (16 G) or 18-gauge (18 G) needles. We included randomized trials and cohort studies of real-time ultrasound-guided biopsies, including case series. MEDLINE, Embase, and CENTRAL were searched through October 2024. Two reviewers independently performed study selection, data extraction, and risk of bias assessment using Joanna Briggs Institute tools. Random-effects meta-analyses estimated pooled proportions with 95% confidence intervals (CI), and univariable random-effects meta-regression explored study-level associations with major complications, transfusion, or gross hematuria. We screened 4,499 titles and abstracts and reviewed 319 full-text articles; 62 studies comprising 68 biopsy series were included. The pooled major complication rate in studies using 16 G needles was 1.83% (95% CI: 1.20-2.79) and 1.29% (95% CI: 0.78-2.13) in studies using 18 G needles, with no statistically significant difference. Mean glomerular yield was 18.8 with 16 G and 17.5 with 18 G needles. In study-level meta-regression, studies with higher prevalence of acute kidney injury, lower mean estimated glomerular filtration rate, or lower mean hemoglobin reported higher pooled complication rates. Most studies were single-arm cohorts; between-needle differences therefore reflect indirect study-level contrasts. Interpretation is limited by retrospective design and heterogeneity across studies. Overall, studies using both needle sizes reported low complication rates and similar diagnostic yield, although definitions and reporting varied. Direct comparative studies are needed to determine whether meaningful differences exist. What was knownKidney biopsy is essential for diagnosing many medical kidney diseases and guiding treatment, requiring adequate tissue samples for subsequent analyses.Modern biopsy techniques use spring-loaded, ultrasound-guided devices with smaller gauge needles, but optimal needle size remains uncertain.While 14G needles are associated with higher complication risk, evidence on whether 16G or 18G needles differ in safety or diagnostic yield is conflicting.This study addsIn this systematic review and meta-analysis of 62 studies involving 22,208 adult native kidney biopsies, we found no statistically significant difference in major complication rates between studies using 16G and 18G needles.In study-level meta-regression analyses, studies with a higher prevalence of acute kidney injury, lower mean estimated glomerular filtration rate, and lower mean hemoglobin reported higher pooled major complication rates.Potential impactStudies using both 16G and 18G needles reported similarly low major complication rates, although comparisons are based on indirect evidence with substantial heterogeneity.Findings support the ethical feasibility and clinical relevance of a large, randomized controlled trial to definitively guide needle size selection in native kidney biopsies.
26 May 2026
Read appraisal →Renal failure
Prognostic factors in malaria patients with acute kidney injury: a systematic review and meta analysis
This systematic review and meta-analysis aims to evaluate the predictors of mortality in malaria patients with AKI. Studies were searched in PubMed, Scopus, Ebsco, and ScienceDirect. We included observational studies that showed the association between clinical or laboratory abnormalities and mortality, reported in odds ratio. The quality of each study was assessed using the Newcastle-Ottawa Scale. Meta-analysis was performed using R. Sixteen studies with 1,104 patients were analyzed. Factors significantly associated with mortality were respiratory distress syndrome (OR: 18.50, p < 0.001), neurological involvement (OR: 12.83, p < 0.001), disseminated intravascular coagulation (OR: 12.00, p < 0.001), hypotension (OR: 18.23, p < 0.001), oliguria (OR: 3.41, p = 0.002), ventilator requirement (OR: 30.35, p < 0.001), leukocytosis (OR: 4.87, p = 0.003), hyponatremia (OR: 3.67, p = 0.048), acidosis (OR: 4.88, p < 0.001), hyperkalemia (OR: 3.99, p < 0.001), and jaundice (OR: 5.03, p = 0.001). ARDS, neurological involvement, DIC, hypotension, oliguria, ventilator requirement, leukocytosis, hyponatremia, acidosis, hyperkalemia, and jaundice were associated with mortality in malaria patients with AKI. The findings underscored the importance of heightened awareness and vigilance in managing patients with these conditions.
26 May 2026
Read appraisal →European journal of pediatrics
Pediatric Trauma Score (PTS) combined with blood lactate measurement provides clinical treatment guidance and prognosis prediction for children with compound injuries: a prospective study
UNLABELLED: Compound injuries in children are the leading cause of death and disability, and early and accurate assessment is crucial to optimize treatment. This study aimed to explore the clinical value of Pediatric Trauma Score (PTS) combined with blood lactate measurement in the triage, treatment guidance and prognosis prediction of pediatric compound injuries. From January 2023 to December 2024, a randomized, single-blind controlled trial was conducted in the emergency department of Hebei Provincial Children's Hospital (the only tertiary pediatric medical center in Hebei Province), China. A total of 546 children with compound injuries who presented to the hospital were included and randomly divided into the intervention group (n = 273, managed by PTS combined with dynamic monitoring of blood lactate) and the control group (n = 273, managed by PTS only). The main outcomes were the timeliness of rescue (time to critical intervention) and the accuracy of prognosis prediction (predictive effectiveness of mortality and major complications). Secondary outcomes included emergency department length of stay, unplanned Intensive Care Unit (ICU) admission, and 30-day complication rate. The median time from admission to initiation of key interventions was significantly shorter in the intervention group compared with the control group (45 [interquartile range (IQR): 30-65] min vs. 68 [IQR: 45-95] min, P < 0.001). The area under the receiver operating characteristic (ROC) curve (AUC) of the combined indicator (PTS + initial lactate) to predict 30-day mortality was 0.936 (95% CI: 0.902-0.970), which was significantly higher than PTS alone (AUC: 0.812, P < 0.001) or initial lactate (AUC: 0.855, P = 0.002). The emergency department length of stay, unplanned ICU admission rate and 30-day complication rate of the intervention group were significantly lower than those of the control group (all P < 0.05). Dynamic monitoring showed that 6-h lactate clearance < 30% was a strong independent predictor of the occurrence of multiple organ dysfunction syndrome (MODS) (odds ratio (OR) = 5.42, 95% CI: 2.88-10.21,P < 0.001. CONCLUSION: The combined application of PTS and blood lactate integrates physiological status and metabolic information, which can significantly improve the accuracy of early triage of pediatric compound injuries, guide the implementation of rescue measures, and effectively predict prognosis through dynamic monitoring, providing a reliable basis for precise personalized management. WHAT IS KNOWN: • Compound injuries in children are the leading cause of death and disability, and early and accurate assessment is crucial to optimize treatment. WHAT IS NEW: • The combined application of the Pediatric Trauma Score (PTS) and blood lactate signifi cantly improves the accuracy of early triage and 30-day mortality prediction, shortens the time to critical intervention, and reduces unplanned ICU admission and 30-day complication rates in pediatric compound injuries. • Dynamic monitoring shows that 6-hour lactate clearance 30% is a strong independent predictor of multiple organ dysfunction syndrome (MODS).
25 May 2026
Read appraisal →Hepatology communications
Midodrine versus placebo in patients with acute-on-chronic liver failure with ascites-A randomized trial (MIDAS trial)
BACKGROUND: Ascites is common in patients with acute-on-chronic liver failure (ACLF) and can complicate the course of ACLF due to circulatory dysfunction and hemodynamic compromise. Oral midodrine has been variably reported to improve hemodynamics and reduce complications of ascites in patients with decompensated cirrhosis, but its role in patients with high MELD ACLF remains unknown, which we aimed to assess. METHODS: In this single-center, double-blind, randomized trial, patients with ACLF were assigned 1:1 to receive midodrine (5-7.5 mg tid) or a placebo for 30 days, alongside standard care. Transplant-free survival (TFS) at 1 month was the primary outcome, while secondary outcomes included TFS at 3 months, the proportion of patients achieving ascites control, changes in mean arterial pressure (MAP) and plasma renin activity at 1 month, the incidence of cirrhosis complications, and diuretic-related complications. RESULTS: One hundred thirty patients with ACLF were enrolled. Midodrine use was not associated with improvement in TFS at 1 (HR, 0.99 [95% CI: 0.37-2.65]) and 3 months (HR, 0.93 [95% CI: 0.48-1.8]). Ascites control at day 30 (placebo: 9.2% [95% CI: 3.5-19] vs. midodrine: 20% [95% CI: 12.3-33.5]; p=0.08) and 90 (placebo: 44.6% [95% CI: 32.2-57.5] vs. midodrine: 53.8% [95% CI: 41-66.3]; p=0.29) was comparable. Midodrine increased the MAP (1.9 vs. 6.9 mm Hg; p=0.003) with an insignificant reduction in plasma renin activity levels (delta change: 0.22±1.6 vs. -1.6±2.2; p=0.09). Cirrhosis-related and diuretic-related complications were similar in both groups. CONCLUSIONS: Midodrine increases MAP in patients with ACLF and high MELD scores without TFS benefit and does not reduce the rate of ascites-related complications.
25 May 2026
Read appraisal →BMC research notes
Survey to evaluate clinical benefits and acceptance in international tele-intensive care unit collaboration
OBJECTIVES: Tele-intensive care unit (TICU) networks have evolved quickly in recent years and have proved their value in providing care for the critically ill. Objective measures to assess performance and quantify success e.g. clinical and economic outcome parameters are desirable but not easily accessible in international collaboration with very diverse clinical settings and legal prerequisites. Therefore, we initiated a study to evaluate the performance in our tele-intensive care unit network. METHODS: We conducted an online survey addressing clinical staff at ten spoke sites in four countries connected to one TICU hub to assess subjective clinical benefit, acceptance and potential for improvement. RESULTS: The majority of the 30 participants felt well supported clinically and personally, with a high acceptance and trust as well as a positive working relationship in tele-medical collaboration. Ethical principles and data protection were discovered to be persistently of utmost significance in tele-intensive care unit networks. CONCLUSION: International telemedicine in critical care is perceived positively without major differences between diverse health care systems when crossing borders, showing potential for improvement to guide future clinical and research approaches. Clinical trial registiry: The study was registered on August 11th, 2023 with the German Clinical Trials Register (DRKS-IDDRKS00032246; https://www.drks.de/search/de/trial/DRKS00032246/details ).
24 May 2026
Read appraisal →Medicine
Efficacy of traditional Chinese medicine in treating severe pneumonia: A meta-analysis and systematic review
BACKGROUND: Severe pneumonia (SP) is a critical respiratory disease characterized by its severity and high mortality rate. Traditional Chinese medicine (TCM) has gradually been used as an adjunctive therapy in clinical treatment of SP, yet its efficacy and safety lack systematic evidence. This study aims to analyze, evaluate, and compare current research evidence on TCM adjunctive therapy for SP, providing a basis for clinical treatment of this condition. METHODS: A systematic search was conducted on both English and Chinese online databases (PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP) to identify relevant papers published from inception to November 2023. High-quality randomized controlled tests (RCTs) were selected for analysis. Outcome measures related to SP were extracted from the literature. Statistical analysis was performed using RevMan 5.3 (Cochrane) software to assess heterogeneity among included studies, calculate mean differences, odds ratios, and their 95% confidence intervals, and detect publication bias. RESULTS: A total of 34 RCTs met the inclusion criteria. Comparative analysis revealed that integrating TCM with conventional treatment significantly improves the overall clinical effective rate(P < .05). Specifically, it markedly alleviates TCM symptoms (P < .05). Additionally, TCM adjunctive therapy reduces levels of inflammatory markers including white blood cells, C-reactive protein (P < .05), and decreases Clinical Pulmonary Infection Score and Acute Physiology and Chronic Health Evaluation II scores compared to conventional treatment alone (P < .05). Compared to conventional treatment alone, TCM adjunctive therapy also enhances arterial blood gas indices (PaO2) (P < .05) and pulmonary function (forced expiratory volume in 1 second) (P < .05). Complication rates and mortality are lower in the TCM adjunctive therapy group(P < .05). Moreover, TCM treatment significantly boosts immune function (cluster of differentiation 4+ T lymphocyte) (P < .05). CONCLUSION: Integrating TCM with conventional treatment shows advantages in the efficacy of SP treatment, clinical symptoms management, inflammatory markers, and severity grading. Compared to conventional treatment alone, TCM adjunctive therapy improves immune function, pulmonary function, complication rates. However, future research should focus on large-scale, high-quality RCTs to further validate the effectiveness and safety of TCM adjunctive therapy for SP.
24 May 2026
Read appraisal →Lancet (London, England)
Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication
BACKGROUND: Patients with extensive ischaemic change are often excluded from endovascular thrombectomy. We aimed to synthesise the evidence from recent trials in these patients by performing a systematic review and individual patient data meta-analysis to estimate treatment benefit, including within clinical and imaging subgroups. METHODS: In this systematic review and meta-analysis, we searched PubMed and Embase for randomised trials published between March 1, 2018, and March 1, 2025, that evaluated efficacy and safety of endovascular thrombectomy compared with medical management in patients with large-core ischaemic stroke (based on an Alberta Stroke Program Early CT Score [ASPECTS] of ≤5 or estimated ischaemic core ≥50 mL) presenting within 24 h of onset. Individual patient-level data from all eligible trials were obtained. A central imaging core laboratory readjudicated ASPECTS and reanalysed ischaemic core volume. A two-stage meta-analysis with random-effects model was used to evaluate the distribution of 90-day modified Rankin Scale (mRS) scores (the primary outcome) using adjusted pooled generalised odds ratios (aGenORs). Missing data were handled by multiple imputation. Safety outcomes were all-cause mortality within 90-day follow-up and neurological worsening within 24-48 h of randomisation, reported as adjusted pooled relative risk (aRR); and symptomatic intracerebral haemorrhage within 36 h of randomisation (reported as risk difference). Subgroup analyses based on clinical and imaging characteristics were done, including subgroups defined by ischaemic core volume, ASPECTS, and time window from onset to randomisation. The meta-analysis was registered with PROSPERO (CRD420251058584). FINDINGS: We included 1886 patients (944 assigned to endovascular thrombectomy and 942 assigned to medical management) from six trials. Baseline characteristics were similar between treatment groups. At day 90, the distribution of mRS scores was improved in patients in the endovascular thrombectomy group (median score 4 [IQR 3-6]; n=940) versus those in the medical management group (5 [4-6]; n=931; aGenOR 1·63 [95% CI 1·42-1·88], p<0·0001). The endovascular thrombectomy group also had reduced mortality (292 [31·1%]) compared with the medical management group (347 [37·3%]; aRR 0·82 [95% CI 0·70-0·97], p=0·022). No significant differences were observed in symptomatic intracranial haemorrhage (ten [1·1%] of 944 vs nine [1·0%] of 942 patients; pooled unadjusted risk difference -0·17 percentage points [95% CI -1·01 to 0·67], p=0·69) or neurological worsening (197 [22·0%] of 896 patients vs 161 [17·9%] of 899; aRR 1·19 [0·87-1·62], p=0·27). Improved functional outcomes with endovascular thrombectomy were consistent across clinical and imaging subgroups, except for those with an estimated ischaemic core volume of 150 mL or greater, in whom point estimates favoured endovascular thrombectomy, particularly in the early time window (0-6 h), but wide 95% CIs limited interpretation. INTERPRETATION: Endovascular thrombectomy was associated with improved functional outcomes and reduced mortality versus medical management in patients with large-core ischaemic stroke presenting within 24 h of onset. With the exception of very extensive ischaemic changes (core volume ≥150 mL) presenting beyond 6 h, where evidence remains limited, benefit was sustained across ASPECTS and ischaemic core strata for patients presenting up to 24 h after onset. FUNDING: None.
24 May 2026
Read appraisal →Studies in health technology and informatics
Assessing AI-Based Decision Support in Early Sepsis and AKI Recognition
Sepsis and acute kidney injury (AKI) remain among the most critical conditions in acute care, associated with high morbidity and mortality. Early risk recognition is essential but often hampered by nonspecific symptoms. Recent studies have demonstrated that AI- and ML-based Clinical Decision Support Systems (CDSS) can enhance the early detection of sepsis and AKI and support clinical decision-making [1-3]. In May 2025, the University Hospital Augsburg (UKA) integrated an externally developed AI-based CDSS to provide real-time risk predictions for sepsis and AKI. This study evaluates the effectiveness of the system in routine clinical practice using retrospective data from periods before and after its implementation. Primary endpoints include diagnostic accuracy. The results will indicate whether the CDSS contributes to improved early risk recognition and enhanced patient safety in a real-world hospital environment.
24 May 2026
Read appraisal →PloS one
A qualitative study to inform the design and implementation of AI-driven diagnosis: Challenges, barriers, and clinical insights of physicians
INTRODUCTION: Acute febrile illnesses are significant clinical challenge in tropical regions due to overlapping symptomatology among infections such as dengue, scrub typhus, and leptospirosis. This diagnostic dilemma leads to delays in appropriate treatment and negatively impacted patient outcome due to limited diagnostic tool availability. Recent advancement in artificial intelligence (AI) application in healthcare help in developing diagnostic aiding tool in such clinical dilemma. AIMS: Study aimed to explore physicians' perspectives on diagnostic challenges of tropical Acute-febrile-illnesses and assess perceived utility of AI as a supportive tool in clinical decision-making. METHODS: A qualitative interview was conducted using validated semi-structured interview guide using literature and expert opinion and validated by IPR method. To understand the physicians perspective on management infectious diseases in critical care, interview guide administered among ten physicians with 10-30 years of experience across different centres of India. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed using ATLAS.ti software. RESULTS: Four major themes emerged: clinical experience and practice, diagnostic-challenges, diagnostic-parameters and decision-making, and AI integration in clinical-practice. However, no statistical test can be performed since study mainly focused to understand perception of physicians with respect to managing illness and hence prevalence cannot be determined. Diseases such as dengue, scrub typhus, and leptospirosis were reported as most prevalent, particularly during monsoon seasons. Key diagnostic challenges included overlapping symptoms, diagnostic delays, limited sensitivity/specificity of available tests, and cost constraints. Physicians primarily relied on clinical judgment and laboratory findings, despite the limitations. Most of the participants expressed positive attitudes toward the potential of AI as supportive tool, citing its ability to enhance diagnostic accuracy and streamline clinical workflow with proper validation. CONCLUSIONS: Growing in clinical dilemma AI has significant role in diagnosis of tropical fever with integration of the clinical data & physician perspective can successfully able to incorporate in clinical application.
23 May 2026
Read appraisal →The journal of trauma and acute care surgery
Chilling the nerve, easing the pain?: A randomized clinical trial evaluating surgeon-administered bedside percutaneous cryoneurolysis for rib fracture pain.
BACKGROUND: A cornerstone of rib fracture management is multimodal pain control, which includes scheduled nonopioid analgesics, as-needed opioids, regional or neuraxial blockade, and surgical stabilization of rib fractures. However, adverse effect profiles and individual factors limit their use in all patients. Surgeon-administered, ultrasound-guided percutaneous cryoneurolysis performed at the patient bedside is a promising analgesic adjunct. METHODS: We performed a prospective, randomized clinical trial assessing benefit and safety of surgeon-administered percutaneous cryoneurolysis to our existing multimodal rib fracture pain control bundle (standard of care [SoC]) for injured adults aged 18 to 64 years. Patients with fractured ribs 3 to 9 were randomized within 72 hours of admission to receive either surgeon-administered, ultrasound-guided percutaneous cryoneurolysis at the bedside and our multimodal pain control bundle, or SoC alone. Patients undergoing surgical stabilization of rib fractures were excluded. The primary outcome was pain score at discharge. Secondary outcomes included hospital length of stay, intervention-associated adverse events, morphine milligram equivalent (MME) use, Short Form (SF)-12, and McGill Pain Score (Patient Reported Outcomes), which were assessed at discharge and 1-, 3-, and 12-month intervals after discharge. RESULTS: Forty-three patients were randomized: 24 in the intervention arm and 19 in the SoC arm, with 3 screen failures. The median age was 53 years (interquartile range [IQR], 45-60 years), 9 patients (23%) were female, the median Injury Severity Score was 13 (IQR, 10-17), and the median number of rib fractures was 6 (IQR, 4-8). Patients were well matched with no differences between groups. No intervention-associated adverse events were identified. Pain scores, MME use, and Patient Reported Outcomes were not different between groups at discharge, 1 month, 3 months, or 12 months. CONCLUSION: Application of surgeon-administered, ultrasound-guided percutaneous cryoneurolysis at the bedside is safe but was not associated with reduced pain or MME use when compared with SoC. ( J Trauma Acute Care Surg . 2026;100: 863-870. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.
23 May 2026
Read appraisal →The journal of trauma and acute care surgery
Cognitive dysfunction after polytrauma in the absence of traumatic brain injury: A systematic review of incidence.
BACKGROUND: Polytrauma patients frequently experience long-term health impacts, including cognitive impairments. While traumatic brain injury (TBI) is a recognized nonmodifiable cause, polytrauma patients are likely to face cognitive challenges potentially linked to systemic inflammation and multiple surgical interventions even in the absence of TBI. This review aims to describe the incidence and identify factors associated with cognitive dysfunction in adult multiple injury patients without Frank TBI. METHODS: A systematic search was conducted across MEDLINE, CINAHL, EMBASE, and Scopus databases on August 17, 2023, to identify studies reporting on cognitive dysfunction in adults with polytrauma, excluding brain injuries. The Critical Appraisal Skills Programme checklists guided study appraisal, and findings were narratively synthesized. RESULTS: From 2719 articles identified (including one through citation searching), 47 were fully screened, yielding 10 cohort studies for inclusion. The reported incidence of cognitive dysfunction among multiple injury patients without TBI varied widely, from 0% to 60%, with a majority (eight out of ten studies) noting incidences of 30% or higher. No consensus was found for a relationship of other studied factors with cognitive dysfunction. Injury Severity Score was found to not be associated with cognitive dysfunction in selected studies which analyzed this factor. CONCLUSION: This review suggests a high prevalence of cognitive dysfunction in multiple injury patients without TBI. The evidence base is limited by heterogeneity of the inclusion criteria, and the cognitive outcome measures. IMPLICATIONS OF KEY FINDINGS: Multiple injury is associated with long term cognitive dysfunction even without primary brain injury. This aspect of the disease of multiple injury needs further characterization to identify predictors and potential preventive and therapeutic interventions. Standardized reporting is also required to be able to monitor incidence and prevalence. ( J Trauma Acute Care Surg . 2026;100: 973-981. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review; Level II.
23 May 2026
Read appraisal →ACS sensors
Moisture-Gated Bio-Semiconductor Electronic Tattoos for Continuous and Imperceptible On-Skin Respiratory Monitoring
Continuous respiratory monitoring remains one of the most critical yet unmet needs in personal and clinical healthcare. To overcome the limitations of cumbersome systems and motion-prone wearables, we present a moisture-gated bio-semiconductor-based electronic tattoo (BSET) that enables imperceptible, skin-conformable, and wireless respiratory monitoring by leveraging the hydration-sensitive ionic-electronic conductivity of melanin and the skin-compatibility of silk. Fabricated from a silk fibroin-melanin nanofiber bio-composite, the BSET is ultrathin at 18 μm and highly breathable, achieving a water vapor transmission rate exceeding 3000 g·m-2·d-1. By detecting exhaled moisture directly on the philtrum, the sensor exhibits a rapid response time of 1 s and a recovery time between 2 and 10 s. A direct-spun nanofiber-based wiring strategy ensures robust integration, accommodating a 10 mm displacement under 10.4 MPa of stress without failure. Driven by a compact 3 g circuit with 20 mW of power consumption, the system supports continuous wireless data transmission for over 7.3 h. During vigorous exercise and sleep, the BSET reliably monitored respiratory dynamics, identifying 10-20 s apnea events and enabling multiparameter analysis of breathing frequency and exhalation intensity. This lightweight system establishes a scalable and clinically relevant solution for continuous respiratory surveillance.
23 May 2026
Read appraisal →PloS one
Double-cuff versus single-cuff bronchial blockers for video-assisted thoracoscopic lobectomy: A randomized controlled trial
BACKGROUND: Bronchial blockers (BBs) manage airways during thoracoscopic lobectomy and isolate lungs by occluding the bronchus at the surgical site. However, intraoperative malpositioning remains a concern. We compared the performance of a new double-cuff BB (DcBB) with an additional cuff near the end of a single-cuff BB (ScBB) with that of ScBBs during thoracoscopic lobectomy. METHODS: This single-center, randomized, parallel, controlled clinical study enrolled 80 patients undergoing thoracoscopic lobectomy for lung cancer at Nanpi People's Hospital. The patients were randomized into two groups (n = 40 each); DcBB (DcBB used during one-lung ventilation) and ScBB (ScBB used during one-lung ventilation). The primary outcomes were the incidence and number of BB malpositioning. Secondary outcomes time for BB placement and positioning, surgical duration, hypoxemia, incidence of adverse cardiovascular events, grades of lung collapse, surgeon satisfaction, tracheal wall damage assessed during bronchoscopy, contamination rates of the non-surgical lung lobe on the surgical site determined by bronchoscopy, radiographic incidence of pulmonary infiltration on postoperative day 1, and intraoperative blood gas values. RESULTS: The incidence of malpositioning was significantly lower in the DcBB than the ScBB group (7.5% vs. 30%, P = 0.02). The incidence of malposition was significantly lower in the DcBB cohort (P = 0.002). However, positioning the DcBB required more time (32.28 ± 5.37 vs. 19.90 ± 4.16 sec, P < 0.001). Other secondary outcomes did not differ significantly. CONCLUSIONS: In patients undergoing thoracoscopic lobectomy, the DcBB was associated with a lower incidence of malposition than the ScBB. The DcBB did not increase tracheal wall injury or cause significant adverse hemodynamic effects, and therefore may serve as a promising optional device for airway management during thoracoscopic lobectomy, particularly in clinical scenarios requiring high placement stability. TRIAL REGISTRATION: the Chinese Clinical Trial Registry ChiCTR2400086472.
22 May 2026
Read appraisal →Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Pharmacokinetics of Dexamethasone in Tuberculous Meningitis
BACKGROUND: Dexamethasone is recommended as adjunctive therapy for tuberculous meningitis (TBM). Co-administration with rifampicin is expected to reduce dexamethasone exposure in TBM, an effect that may be more pronounced with the higher rifampicin doses currently being evaluated in clinical trials. METHODS: This pharmacokinetic study was nested in a randomized controlled trial comparing the safety of high-dose rifampicin (oral, 35 mg/kg; intravenous, 20 mg/kg) plus linezolid, with or without aspirin, versus standard-dose rifampicin (10 mg/kg) for adults with HIV-associated TBM. All participants received adjunctive oral dexamethasone every 12 hours starting at a dose of 0.4 mg/kg/day. Dexamethasone concentrations were measured on intensively sampled plasma on day 3 after study enrollment and analysed using nonlinear mixed-effects modeling. RESULTS: In total, 261 dexamethasone concentrations from 43 participants were available for model development. Eight (18%) participants were on efavirenz-based ART and five (11%) were on a lopinavir/ritonavir-based regimen. The median duration of rifampicin therapy at the time of pharmacokinetic sampling was 4 days (range: 0-7). Dexamethasone pharmacokinetics was best described by a one-compartment disposition model with first-order absorption and elimination. Typical oral clearance (CL/F) was 131 L/h, reduced to 11.5 L/h with concomitant lopinavir/ritonavir. High-dose rifampicin had no significant additional effect on dexamethasone pharmacokinetic parameters compared with the standard-dose. CONCLUSIONS: In adults with HIV-associated TBM, there was high dexamethasone clearance, likely related to a drug-drug interaction with rifampicin. High-dose rifampicin had no additional effect on dexamethasone exposure.
22 May 2026
Read appraisal →ACS applied materials & interfaces
Breathable Bioadhesive Electronic Skin for Precise Multimodal Electrophysiological Monitoring with AI-Assisted Physiological-State Prediction
Accurate and stable monitoring of electrophysiological (EP) signals is essential for wearable healthcare applications. However, conventional commercial electrodes suffer from poor conformal contact, limited breathability, and weak adhesion under sweaty skin and human motion condition, leading to unstable skin-electrode interface and low-quality signal acquisition. Moreover, single-modality EP signal measurements are insufficient for reliable physiological and health evaluation. Herein, we develop a multimodal electrophysiological signal monitoring electrode (MESME) featuring a fiber membrane combining thermoplastic polyurethane (TPU) and poly(acrylic acid) functionalized with N-hydroxysuccinimide ester (PAA-NHS), seamlessly integrated with a liquid metal (LM) serpentine conductive path. Compared with commercial electrodes (gel-based wet electrode), this MESME exhibits high mechanical flexibility and conformability, superior breathability, robust bioadhesion, stable electrical performance under perspiration, and motion conditions and lower interfacial impedance, enabling high-fidelity multimodal signal acquisition. Leveraging this capability, the multimodal signals generated by MESME can be further integrated with deep learning for drowsiness prediction, achieving a validation accuracy of 97.14%. This platform offers a practical strategy for multimodal electrophysiological monitoring and supports future development of data-driven health assessment models.
21 May 2026
Read appraisal →Physiological measurement
Perioperative hypoxaemia early warning based on high-frequency waveform fusion and deep learning
Objective.The accurate prediction of impending intraoperative hypoxaemia events is paramount for patient safety. Current models relying on structural parameters exhibit limitations, including low sampling frequency, weak temporal coherence, and high data attrition rates. Consequently, long-term sequence, high-frequency waveform data are utilised in this study to construct a deep learning-based hypoxaemia prediction model, by which conventional shortcomings are addressed whilst predictive accuracy and robustness are enhanced.Approach.Respiratory, blood oxygenation, and electrocardiogram waveforms were extracted from the VitalDB database. Two processing methods were employed: extraction of waveform-derived variables to construct numerical datasets; and utilisation of the Gramian Angular Summation Field (GASF) and the four-quadrant matrix method to construct image-based datasets. Through multiple dataset construction methods, five datasets were constructed. An LSTM algorithm was employed, using a 5 min learning window and prediction windows ranging from 1 to 13 min, to conduct a comprehensive performance evaluation.Main results.Optimal performance was achieved by all models within a one-minute prediction window. Highly competitive accuracy (0.932), AUC (0.953), and stability (maximum AUC variance 0.067) were demonstrated by the 'Multimodal image model', whilst the poorest performance was exhibited by the 'structured only model'. Moreover, compared to singlemodal models, multimodal models incorporating structured parameters yield only marginal improvements. Consequently, singlemodal data derived solely from raw waveforms are suggested as sufficient for prediction requirements, by which greater application potential is held due to enhanced computational efficiency.Significance.This study systematically demonstrated the significant advantages of high-frequency waveform data. Results indicate that waveform processing methods based on the GASF and the four-quadrant matrix approach can effectively enhance model stability and performance. Furthermore, the singlemodal model relying solely on waveform data, excluding structured parameters, can meet clinical prediction requirements while reducing computational costs. This study provides novel data structures and methodologies for perioperative hypoxaemia prediction.
20 May 2026
Read appraisal →Disaster medicine and public health preparedness
Hospital Medical Surge Capacity Assessment and Planning Tools for Disaster Response: A Systematic Review and Meta-analysis
BACKGROUND: Hospital surge capacity is pivotal for disaster response, yet the effectiveness of assessment and planning tools remains underexplored. OBJECTIVE: This systematic review evaluates the reliability, validity, and applicability of surge capacity tools across disaster scenarios. METHODS: Following PRISMA guidelines, we analyzed 24 Q1 studies (PubMed, Scopus) using the PICO framework. Risk of bias was assessed via ROBINS-E, and meta-analysis (random-effects model) quantified pooled effect sizes (ES). Subgroup analyses compared simulation tools, surveys, and resource strategies. RESULTS: The combined ES was 0.74 (95% CI: 0.67-0.82), indicating moderate improvement in preparedness. Simulation tools (Group A) showed the highest consistency (ES = 0.81, I2 = 0%), while resource strategies (Group C) had wider variability (ES = 0.71, I2 = 74.42%). Egger's regression revealed publication bias (P = 0.004), and heterogeneity was substantial (I2 = 76.70%). CONCLUSIONS: Simulation-based tools are most effective for surge capacity, whereas resource strategies require contextual adaptation. Policymakers should prioritize standardized benchmarks and DSS integration, with future research addressing equity and real-world implementation gaps.
20 May 2026
Read appraisal →JAMA
Using Serious Games to Increase the Implementation of Trauma Triage Guidelines: A Randomized Clinical Trial
IMPORTANCE: Low-cost methods that improve physician adherence to clinical guidelines are lacking. Trauma triage exemplifies time-sensitive conditions where guideline adherence remains at 50% or less despite stakeholder efforts, particularly when treating older adults. OBJECTIVE: To determine whether a theory-based serious game (a purpose-driven video game) improves emergency physician adherence to trauma triage guidelines for older adults. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial recruited 800 emergency physicians responsible for the triage of Medicare fee-for-service injured patients (≥65 years of age) at emergency departments within nontrauma centers in the US. Physician enrollment began November 27, 2023, and concluded February 7, 2024. Data collection began January 1, 2024 (or the date of enrollment), and ended February 6, 2025. The patients were treated during the 1 year after physician enrollment. INTERVENTIONS: Game-based training on a tablet for an initial session of 2 hours and then a 20-minute session each quarter (4 doses; n = 400 physicians) vs usual education (n = 400 physicians). MAIN OUTCOMES AND MEASURES: The primary outcome was undertriage (defined as the proportion of severely injured patients not transferred to trauma centers) during the year after randomization. The secondary outcomes were overtriage (defined as the proportion of transferred patients with minor injuries) and a composite clinical outcome of 30-day mortality or hospital readmission. Medicare fee-for-service claims were analyzed using mixed-effects regression models. RESULTS: Of the 800 physicians, the length of experience was a median of 10 (IQR, 6-17) years in practice, 71% were male (563/789), and 750 (94%) had completed Advanced Trauma Life Support. The physicians worked at 1147 hospitals and treated 41 073 injured Medicare patients, of whom 1738 (4.2%) had severe injuries. Of the physicians in the game-based training (intervention) group, 99% (397/399) received 1 dose and 67% (268/399) received 4 doses. Physicians in the game-based training group had a lower proportion of severely injured older adults who were undertriaged (49%; 402/819) compared with the usual education (control) group (57%; 527/919) (model-adjusted difference, -7% [95% CI, -13% to -0.8%]; P = .02). The model-adjusted difference did not differ for the outcomes of overtriage (-3% [95% CI, -6% to 1%]; P = .14) and the composite outcome (-0.4% [95% CI, -5% to 4%]; P = .87). CONCLUSIONS AND RELEVANCE: Among physicians responsible for the triage of patients in emergency departments of nontrauma centers, use of a theory-based serious game decreased the proportion of severely injured patients who were undertriaged. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06063434.
20 May 2026
Read appraisal →Journal of the American Heart Association
Soluble Thrombomodulin Links Viremia and Mortality During COVID-19: Results From the ACTIV-4a Trial
BACKGROUND: COVID-19 and other respiratory viral infections can cause cardiovascular complications. SARS-CoV-2 virions are found in the blood, and circulating viral RNA levels are associated with death. We hypothesized that viremia can induce thrombotic endotheliopathy that contributes to death and studied this relationship in patients hospitalized for COVID-19 and enrolled in the ACTIV-4a (Accelerating COVID-19 Therapeutic Interventions and Vaccines) randomized trial of antithrombotic therapy. METHODS: We quantified SARS-CoV-2 nucleocapsid RNA and protein in plasma and measured their associations with clinical outcomes and biomarkers of thromboinflammation and endotheliopathy. We used Cox regression and Fine-Gray competing risk models to analyze survival and thrombosis. We conducted causal mediation analysis to explore whether thrombotic endotheliopathy mediates the relationship between viral RNA and death. RESULTS: In 93 patients, SARS-CoV-2 RNA and N-antigen were higher in nonsurvivors. Baseline viral RNA levels were associated with increased 90-day death (hazard ratio [HR], 1.31 [95% CI, 1.17-1.46]) and thrombosis (HR, 1.35 [95% CI, 1.24-1.47]). Viral RNA more effectively predicted survivorship than N-antigen levels. Soluble thrombomodulin, a biomarker of thrombotic endotheliopathy, positively correlated with viral RNA levels. Mediation analysis revealed that soluble thrombomodulin accounts for 12.2% (95% CI, 0.1%-32.3%; P=0.048) after adjustment for age and sex of the relationship between viral RNA and the 90-day mortality rate. CONCLUSIONS: Elevated plasma SARS-CoV-2 RNA levels are associated with death in ACTIV-4a, which is causally mediated in part by soluble thrombomodulin. We propose that lung-blood viral dissemination is a potential mechanism for cardiovascular complications of respiratory viruses. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04505774.
20 May 2026
Read appraisal →Emerging microbes & infections
Clinical outcomes of carbapenem therapy in OXA-48-producing Enterobacterales infections: a French multicentre cohort, systematic review, and meta-analysis
OXA-48-producing Enterobacterales (OXA-48-PE) represent a growing global health threat. Most of OXA-48-PE remain categorized susceptible to carbapenems, which might encourage their use despite uncertain clinical efficacy. This study evaluated clinical outcomes of infections caused by OXA-48-PE treated with carbapenem compared with alternative active therapies. The analyses were performed at three levels: a descriptive analysis of the French cohort, a comparative descriptive analysis of all published studies, and a meta-analysis restricted to studies providing direct comparisons between carbapenem-based and alternative active regimens. Between September 2021 and March 2023, 59 patients with monomicrobial OXA-48-PE infections were included in a French multicenter retrospective cohort. In parallel, a systematic review was conducted to identify clinical studies published through 31 December 2024, reporting outcomes of OXA-48-PE infections. In the French cohort, the overall 30-day mortality was 49.1%. Clinical failure occurred in 57.1% of patients receiving meropenem monotherapy, including patients infected with isolates exhibiting meropenem MICs within the susceptible range. Across 12 clinical studies (817 patients), carbapenem therapy was associated with high and variable crude mortality (52%), whereas newer agents active against OXA-48-PE, particularly ceftazidime-avibactam, were associated with lower and more consistent crude mortality (30.7%). In the primary meta-analysis of 6 human comparative studies, carbapenem therapy was associated with an increased risk of clinical failure compared with alternative active regimens (OR = 2.02; 95% CI = 1.05-3.88). Despite apparent in vitro susceptibility, carbapenem therapy was consistently associated with unfavourable clinical outcomes in OXA-48-PE infections, supporting the prioritization of alternative active agents whenever available.
20 May 2026
Read appraisal →Journal of the American Heart Association
Sex Differences Among Young Patients With ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis
BACKGROUND: Female sex is associated with lower incidence of myocardial infarction, especially at younger ages. However, sex differences in mortality and coronary artery disease patterns among young patients with ST-segment-elevation myocardial infarction are not well established. This study evaluated sex differences in in-hospital and 1-year all-cause death and in the extent of coronary artery disease in patients aged ≤45 years with ST-segment-elevation myocardial infarction. METHODS: A systematic review (December 9, 2025) was conducted using PubMed, Cochrane, Embase, major cardiology conference proceedings, and ClinicalTrials.gov. Studies comparing sexes for outcomes were included. Non-English publications, abstracts without full text, and studies published before 2010 were excluded. A random-effects meta-analysis was performed, with results presented as relative risks (RR) and 95% CIs. Heterogeneity was assessed using τ and I2, risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. The study was registered on the International Prospective Register of Systematic Reviews. RESULTS: Eleven studies including 738 029 patients with ST-segment-elevation myocardial infarction (22% women) were analyzed. Female sex was associated with higher unadjusted in-hospital (RR, 1.56 [95% CI, 1.40-1.74]; τ=0.04; I2=0%) and 1-year mortality rate (RR, 1.78 [95% CI, 1.50-2.12]; τ=0.00; I2=0%). Women more frequently had single-vessel disease (73% versus 60%; RR, 1.13 [95% CI, 1.03-1.23]; τ=0.07; I2=67%), while men had 2-vessel (23% versus 18%; RR, 0.76 [95% CI, 0.68-0.85]; τ=0.00; I2=0%;) and 3-vessel disease (16% versus 9%; RR, 0.49 [95% CI, 0.27-0.86]; τ=0.41; I2=33%). CONCLUSIONS: In young patients with ST-segment-elevation myocardial infarction, female sex is associated with higher unadjusted in-hospital and 1-year death despite less extensive CAD. Further studies adjusting for comorbidities and standardizing CAD definitions are needed.
20 May 2026
Read appraisal →Annals of medicine
Endovascular thrombectomy versus best medical therapy for acute vertebrobasilar artery occlusion in patients with low NIHSS scores: a meta-analysis
OBJECTIVE: The efficacy of endovascular thrombectomy (EVT) for acute vertebrobasilar artery occlusion (VBAO) presenting with mild symptoms (National Institutes of Health Stroke Scale [NIHSS] score ≤10) remains uncertain. This meta-analysis aimed to compare the effectiveness and safety of EVT versus best medical therapy (BMT) in this population. METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to September 2025 for comparative studies. The primary outcome was 90-day excellent functional outcome (modified Rankin Scale [mRS] score 0-1). Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS: Seven observational studies involving 3,107 patients were included. In unadjusted analyses, EVT was associated with a higher rate of excellent functional outcome (OR 2.17; 95% CI 1.58-2.96) but not with functional independence (OR 1.58; 95% CI 0.90-2.77). After adjustment for confounders, EVT was associated with higher rate of excellent functional outcome (OR 2.86; 95% CI 1.89-4.31) and functional independence (OR 1.91; 95% CI 1.01-3.62). Safety outcomes including sICH and mortality did not differ significantly between groups. CONCLUSION: In patients with acute VBAO and mild symptoms, EVT may be associated with superior functional outcomes compared to BMT alone, without a significant increase in procedural risks. These findings suggest a potential role for EVT in selected patients with low NIHSS scores and underscore the need for confirmation in randomized trials.
18 May 2026
Read appraisal →Lancet (London, England)
Ticagrelor with aspirin dual antiplatelet therapy combined with intravenous thrombolysis in patients with ischaemic stroke in China (TAPIS): a multicentre, double-blind, randomised controlled trial
BACKGROUND: Evidence supporting the early addition of antiplatelet therapy to intravenous thrombolysis in patients with acute ischaemic stroke remains inconclusive. We aimed to investigate the efficacy and safety of early oral dual antiplatelet therapy (DAPT), started within 6 h of onset, as an adjunct to intravenous thrombolysis. METHODS: TAPIS was a randomised, double-blind, placebo-controlled trial done in 60 hospitals across China. We enrolled patients treated with intravenous thrombolysis for ischaemic stroke, with a National Institutes of Health Stroke Scale score of 4-10. We randomly assigned (1:1) patients to receive oral aspirin plus ticagrelor (DAPT group) or corresponding placebo within 6 h of stroke onset, either before, during, or after receiving thrombolysis. Ticagrelor or placebo was continued for days 2-7 in each group, with open-label aspirin administered for days 2-90. Patients, clinicians, and investigators were masked to the group assignment. The primary efficacy outcome was an excellent functional outcome (modified Rankin Scale score 0-1) at 90 days. The primary safety outcome was symptomatic intracranial haemorrhage within 36 h. This trial was registered with ClinicalTrials.gov (NCT06316570) and is completed. FINDINGS: Between April 3, 2024, and Sept 30, 2025, we randomly assigned 1382 patients to the early DAPT (n=690 [49·9%]) or placebo (n=692 [50·1%]) groups. The median age was 65·6 years (IQR 58·3-72·0), 991 (71·7%) were men, and 391 (28·3%) were women. At 90 days, 474 (68·7%) patients in the early DAPT group and 429 (62·0%) in the placebo group achieved excellent functional outcomes (risk ratio 1·11 [95% CI 1·03-1·20; p=0·0089). Symptomatic intracranial haemorrhage within 36 h occurred in six (0·9%) patients in the early DAPT group versus five (0·7%) in the control group (risk ratio 1·20 [95% CI 0·37-3·93; p=0.76). INTERPRETATION: Among patients treated with intravenous thrombolysis for moderate ischaemic stroke, initiation of oral DAPT within 6 h of onset improved the likelihood of excellent functional outcomes at 90 days. Although no significant between-group difference in symptomatic intracranial haemorrhage was detected, wide CIs precluded exclusion of a small increased risk. FUNDING: National Natural Science Foundation of China, Capital's Funds for Health Improvement and Research, Noncommunicable Chronic Diseases-National Science and Technology Major Project, Beijing Municipal Science & Technology Commission, and the New Cornerstone Science Foundation.
18 May 2026
Read appraisal →JMIR medical informatics
From Flow to Feature Using a Proof-of-Concept Spectral-Driven Machine Learning Approach Using Smart Urinary and Drainage Catheter Systems: Algorithm Development and Validation
BACKGROUND: Current urinary and drainage catheter systems collect fluids for visual inspection or manual sampling, offering limited diagnostic value while being labor-intensive and prone to error. Machine learning (ML) has the potential to automate the analysis of these fluids. However, existing methods rely on complex preprocessing steps, which hinder real-time analysis. OBJECTIVE: We aim to develop and evaluate a fully automated, real-time diagnostic approach for smart urinary and drainage catheter systems by leveraging spectral data and ML to differentiate pathological from healthy excreted fluids without the need for manual preprocessing. METHODS: This study proposes a novel, fully automated approach for smart urinary and drainage catheter systems that uses spectra and ML to extract features from excreted fluids, enabling real-time analysis directly. A total of 454 surgical drainage fluid samples (from 181 patients) and 401 urine catheter samples (from 168 patients) were analyzed using smart catheters and drains equipped with compact mini-spectrometer sensors. The collected spectral data were fed into 3 different ML models: a random forest, a partial least squares discriminant analysis regression, and a convolutional neural network (CNN). Each model aimed to extract features and differentiate between pathological and healthy urine and drainage samples based on the various biomarkers available from previously conducted laboratory analyses. RESULTS: All 3 approaches (random forest, partial least squares discriminant analysis regression, and CNN) achieved promising results, demonstrating the potential of the overall approach. In particular, the CNN models trained on the drainage biomarkers hemoglobin and bilirubin achieved the best results. Matthews correlation coefficient scores of 0.83 and 0.81 were obtained for hemoglobin and bilirubin, respectively, when differentiating between pathological and healthy samples using the extracted spectral features. CONCLUSIONS: This work demonstrates the potential of spectral-driven ML for smart urinary and drainage catheter systems. This approach offers a real-time, noninvasive method for analyzing excreted fluids, paving the way for improved diagnostics and personalized patient care. Further research will explore the optimal ML model for this application.
17 May 2026
Read appraisal →JMIR formative research
Use of Commercially Available Large Language Models to Generate Information Leaflets on Post-Intensive Care Syndrome: Clinical Utility Assessment
BACKGROUND: Patients and their families without medical knowledge may find professional health care information difficult to understand. The use of large language models (LLMs) to simplify and translate complex medical content holds promise for improving comprehension while reducing the burden on health care providers tasked with delivering explanations. OBJECTIVE: This study aims to evaluate the quality of information leaflets generated using commercially available LLMs. METHODS: Informational texts on post-intensive care syndrome were generated using 6 different LLMs and 4 prompt designs with varying levels of instructional guidance. Clinical practice guideline documents were uploaded and provided to the models as reference context, reflecting a pragmatic clinical scenario without model tuning or advanced retrieval pipelines. In total, 72 texts were generated (6 models × 4 prompts × 3 outputs). After excluding texts shorter than 500 characters (n=16) and those without explicit mention of post-intensive care syndrome (n=3), 53 texts remained. To enable balanced human evaluation across model-prompt combinations, the longest eligible response from each pair was selected (4 prompts × 4 models; n=16). Following independent expert review by 2 medical specialists, 7 texts were excluded, leaving 9 texts for final analysis. Ten individuals, including health care professionals and nonmedical personnel, assessed the texts using a 10-point Likert scale across multiple quality domains. An LLM-based parallel assessment was also conducted, and scores were compared across models and evaluator groups. RESULTS: In the human evaluation of the selected 9 texts, the generated texts achieved an average score of 6.8 or higher across all evaluation criteria, with no potentially harmful content identified. The text generated by LLaMA 3 70B, using a step-by-step approach combined with text-augmented prompting based on clinical guidelines, received the highest overall score, whereas the lowest-rated text was produced using a simple prompt without text augmentation. Although no consistent trends were observed across LLMs or prompt engineering strategies, text-augmented prompting was generally associated with higher evaluation scores. Ratings differed between professional and nonprofessional evaluators. Given the feasibility-driven screening process and the resulting limited sample size, the findings should be interpreted as exploratory and descriptive rather than definitive estimates of overall model performance. CONCLUSIONS: Among the selected texts included in the final human evaluation, informational materials generated using commercially available LLMs were generally rated as acceptable by human evaluators, and none contained harmful content. These findings suggest that LLMs may support the development of patient-facing informational materials under feasibility-constrained conditions, although further validation with larger and more diverse samples is warranted.
16 May 2026
Read appraisal →Thorax
Clinical impact of customised positive airway pressure (PAP) therapy interfaces (3DPiPPIn): a single site randomised controlled trial
INTRODUCTION: Positive airway pressure (PAP) therapy is the recognised treatment for sleep disordered breathing (SDB), delivered via a tight-fitting face mask (interface). Conventional interfaces do not consider facial geometries, often resulting in poor fit and ineffective therapy. Three-dimensional (3D) printing of customised interfaces may improve comfort and outcomes. OBJECTIVES: To evaluate the clinical impact of customised versus conventional oronasal interfaces in adults with obstrcutive sleep apnoea (OSA). The primary outcome was residual Apnoea Hypopnea Index (AHI) at 6 months; secondary outcomes included interface leak, therapy concordance and patient reported symptoms. METHODS: A randomised controlled trial with 160 adults naïve to PAP therapy and diagnosed with SDB (AHI ≥15 events/hour). Randomisation was minimised by age and ethnicity. Structured light facial scans (POP2, Revopoint, China) were used to produce 3D printed moulds (Fuse 30+, Formlabs, Massachusetts, USA) for silicone injected oronasal customised interface cushions.AHI was compared using quantile regression to account for the skewed distribution of the AHI data. Secondary outcomes were compared using logistic, quantile and linear regressions. RESULTS: 160 participants were recruited (intervention: 82, control: 78). Customised interfaces were associated with a 1.5 (events/hour) increase in AHI (p=0.059), higher interface leak (difference in medians 30.0 L/min, 95% CI 7.36 to 40.14, p<0.0001) and lower compliance (difference in compliance 0.78, 95% CI 0.05 to 1.54, p=0.04) at 6 months. CONCLUSIONS: This trial did not demonstrate customised oronasal interfaces were superior to conventional interfaces. Future research should focus on addressing design and manufacturing limitations before any potential advantages can be evaluated. TRIAL REGISTRATION NUMBER: ISRCTN74082423.
16 May 2026
Read appraisal →The Journal of infectious diseases
Cytomegalovirus DNAemia in Hospitalized Adults With SARS-CoV-2 Infection Requiring Supplemental Oxygen: Virologic and Clinical Characteristics and Association With Outcomes
BACKGROUND: Cytomegalovirus (CMV) reactivation occurs in the context of coronavirus disease 2019 (COVID-19); however, the viral kinetics, risk factors, and clinical outcomes are poorly defined. METHODS: We examined the association of CMV DNAemia with clinical outcomes among participants of a randomized trial of remdesivir with or without baricitinib (National Institute of Allergy and Infectious Diseases [NIAID], Adaptive COVID-19 Treatment Trial 2 [ACTT-2]). Plasma CMV DNAemia from CMV-seropositive participants with COVID-19 (NIAID ordinal scale [OS] 5, 6, or 7 at entry) were assessed longitudinally by quantitative polymerase chain reaction. Factors associated with CMV DNAemia, and clinical outcomes were analyzed by Cox regression and proportional odds models. RESULTS: Of 772 trial participants with available samples, 643 (83%) were CMV seropositive. Baseline CMV serostatus was not associated with COVID-19 outcomes. The cumulative incidence of CMV DNAemia among seropositive persons by day 28 was overall 11% (baseline OS 5, 6.3%; OS 6, 16.4%; OS 7, 24.7%), and was associated with older age, baseline OS, male sex, lymphopenia, and systemic corticosteroid use, while remdesivir and baricitinib did not affect risk. CMV DNAemia was associated with a lower probability of improvement by day 29 (adjusted hazard ratio, 0.3 [95% confidence interval, .17-.56]), with a more pronounced delay of recovery with higher CMV viral load. CMV DNAemia was also associated with higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and death. CONCLUSIONS: In hospitalized adults with COVID-19 requiring oxygen, CMV viremia occurs within well-defined clinical risks and is independently associated with delayed recovery from illness, higher SARS-CoV-2 viral load, and increased mortality.
16 May 2026
Read appraisal →BMC anesthesiology
Automated end-tidal control versus manual regulation in low-flow volatile anesthesia: a systematic review and meta-analysis
BACKGROUND: In low-flow anesthesia, automated monitoring of end-tidal oxygen (etO2) and end-tidal anesthetic agents (etAA) has been favored to reduce clinicians' cognitive workload during anesthesia maintenance. This systematic review, therefore, aimed to determine the comparative efficacy and safety of automated end-tidal controlled anesthesia (etCA) versus manually controlled anesthesia (MCA). METHODS: An electronic search was conducted across four databases: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Scopus. The retrieved references were then analyzed against the studies' screening and eligibility criteria before the full articles were included in the study. The Review Manager (RevMan 5.4.1) was then used to conduct the statistical analysis of the reported outcomes. RESULTS: The electronic search retrieved 965 articles, among which 10 were included in this review. The studies included a pooled sample size of 1269 who underwent surgical procedures under low-flow anesthesia. The analyzed evidence suggests with low certainty that the type of anesthesia control may not have any significant effect on both the anesthesia duration (SMD - 0.00 min; 95% CI [-0.34, 0.34] p = 0.99) and the procedural duration MCA (SMD 0.04 min; 95% CI; 95% CI [-0.26, 0.33] p = 0.80). Moreover, we found with low certainty in the evidence that the amount of sevoflurane consumed may not be significantly different between etCA and MCA (SMD - 0.32 mLs; 95% CI [-0.94, 0.29] p = 0.31). Our narrative synthesis indicated that etCA can potentially improve anesthesia delivery by reducing the required anesthetist interventions and ensuring stable and accurately administered anesthetics. CONCLUSION: This review found very low-quality evidence suggesting that the type of anesthesia control may not significantly affect anesthesia delivery parameters, such as the amount of anesthesia consumed and procedural and anesthesia duration. The analyses, however, had significant heterogeneity, making the estimates highly unreliable. On the other hand, some studies indicate potential advantages of using etCA, such as reducing the number of interventions required during anesthesia; however, the evidence remains limited, preventing a full exploration of these advantages.
15 May 2026
Read appraisal →BMJ paediatrics open
Prevalence of dysglycemia following paediatric cardiac surgery: a systematic review and meta-analysis
BACKGROUND: Postoperative dysglycemia is a common but under-recognised complication in paediatric cardiac surgery, driven by physiologic stress, hormonal changes and cardiopulmonary bypass. Reported prevalence varies widely, and no meta-analysis has synthesised the evidence. Therefore, this study aimed to estimate the pooled prevalence of postoperative dysglycaemia and describe associated postoperative outcomes, such as intensive care unit (ICU) stay and mechanical ventilation duration. METHODS: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines and the Joanna Briggs Institute (JBI) methodology for prevalence studies. Eligible studies included paediatric patients (≤18 years) undergoing cardiac surgery reporting postoperative dysglycaemia (hyperglycaemia or hypoglycaemia). A random-effects model was used to calculate pooled prevalence and 95%CIs, with logit transformation applied to prevalence proportions and heterogeneity assessed using I² statistics. Subgroup analyses were performed by region/continent, study design, age group and glycaemic threshold. All included studies were critically appraised using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2 tool for randomised trials. The protocol was registered with PROSPERO (CRD420251161893). RESULTS: 22 studies involving 3864 patients were included. The pooled prevalence of postoperative dysglycemia was 68.6% (95% CI 52.8 to 81.0), with hyperglycaemia accounting for most cases (71.2%) and hypoglycaemia observed in 8.1%. Prevalence was higher in Asia and North America (~75%) than in Europe (45.2%), though not statistically significant. Studies using lower hyperglycaemia thresholds (126-139 mg/dL) reported significantly the highest prevalence (82.3%, p<0.032). The pooled mean ICU stay among dysglycemic patients was 180.3 hours (95% CI 82.3 to 279.3), and mean mechanical ventilation duration was 94.6 hours (95% CI 5.2 to 184.1). Sensitivity analyses showed that no single study disproportionately influenced the overall pooled estimates, and no publication bias was detected. The certainty of evidence assessed using the GRADE approach was moderate for overall dysglycemia prevalence. CONCLUSION: Dysglycaemia is highly prevalent following paediatric cardiac surgery, particularly hyperglycaemia, with prolonged ICU and mechanical ventilation times observed among affected patients. These findings underscore the need for vigilant perioperative glucose monitoring, standardised definitions of dysglycaemia, and evidence-based glycaemic management protocols. Future multicentre studies are warranted to establish optimal glycaemic thresholds and evaluate targeted interventions to improve postoperative outcomes in this vulnerable population.
15 May 2026
Read appraisal →PloS one
Evaluation of the diagnostic value of the Modified Evan's Blue Dye Test for assessing aspiration in tracheostomized critically ill patients: A systematic review and meta-analysis
Dysphagia and aspiration are common complications in tracheostomized critically ill patients. The Modified Evan's Blue Dye Test (MEBDT) is a non-invasive, bedside, adjunctive rule-in signal for aspiration when positive. However, its diagnostic accuracy compared to the gold standard Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in these patients remains unclear. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of the MEBDT for the detection of aspiration in tracheostomized critically ill patients. Study protocol was prospectively registered on PROSPERO (CRD:42023479920). A systematic search was performed across three databases (PubMed, Cochrane Central, and Embase), followed by a systematic screening process against predetermined selection criteria and included studies that provided data on the sensitivity and specificity of MEBDT versus FEES. The risk of bias and the level of evidence certainty in the included papers were assessed by the QUADAS-2 tool and GRADE approach respectively. Six out of 2227 screened studies were included. We found that MEBDT had a high specificity 95.42% (95% CI [67.38%, 99.53%]) and positive predictive value 95% (95% CI [81, 100]). In conclusion, the MEBDT can serve as a bedside adjunctive tool that indicates a potential aspiration risk when the result is positive. However, if the result is negative, further diagnostic assessments, like FEES, are recommended for high-risk patients.
15 May 2026
Read appraisal →Journal of clinical microbiology
Prediction of KPC-producing Klebsiella pneumoniae by MALDI-TOF MS, ensemble learning, and spectral peak annotation
The increasing prevalence of carbapenem-resistant Klebsiella pneumoniae represents a serious global health challenge. Rapid and accurate detection methods are essential to inform early and correct use of antimicrobial therapy to idealize patient outcomes and limit the spread of resistant isolates. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been evaluated for resistance detection, but its clinical application remains limited. In this study, MALDI-TOF MS was integrated with machine learning (ML) to improve detection of Klebsiella pneumoniae carbapenemase (KPC) among K. pneumoniae isolates harboring KPC carbapenemase. Ensemble learning strategies were applied to 435 clinical isolates from different geographic locations (Spain, United States, South America, and Asia), with validation performed using external data sets. By constructing two peak matrices and applying four ML algorithms, as well as combinations of two and three in ensemble models, 92 different classifiers were tested. Ensemble combinations increased the specificity of classifiers to over 95%, while sensitivity reached 72%, being significantly higher than that of the MALDI Biotyper KPC module. Low sensitivity may be affected by technical variability during spectral acquisition. The first annotated MALDI-TOF MS spectrum for K. pneumoniae by in silico prediction of protein masses was developed to enable peak identification, including peaks potentially related to antimicrobial resistance. Overall, the results of this study show that combining MALDI-TOF MS with ensemble learning can enhance KPC detection performance.IMPORTANCERapid and accurate detection of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae informs early and correct use of antimicrobial therapy to idealize patient outcomes and limit the spread of antimicrobial resistance. In this study, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and ensemble machine learning were employed to detect KPC-producing isolates, using diverse isolate collections, obtaining excellent specificity. An annotated K. pneumoniae MALDI-TOF MS profile is provided with peak annotation, providing a resource for peak analysis.
14 May 2026
Read appraisal →PloS one
Effects of nebulized dexmedetomidine for premedication on the parameters of oxidative and inflammatory stress in children undergoing tonsillotomy and adenoidectomy: A pilot randomized controlled trial
BACKGROUND: This prospective randomized clinical pilot study aimed to evaluate the effect of inhaled Dexmedetomidine in premedication in children after tonsillectomy with adenoidectomy on oxidative and inflammatory stress and the drugs impact on clinical parameters such as perioperative sedation, hemodynamics, respiratory function, postoperative delirium, analgesia, opioid consumption and frequency of complications. METHODS: Children aged 4-13 years with an indication for tonsillotomy with adenoidectomy were randomized into two groups: (D) - Dexmedetomidine treated group and (N) - control, non-treated group. Ramsey's sedation score, Bispectral index (BIS), and vital signs (heart rate, respiratory rate, noninvasive blood pressure and hemoglobin oxygen saturation) were monitored perioperatively in at defined time points. After 15 minutes of extubation, the postoperative delirium score (PEAD) and pain score (VAS) were noticed. Pain scores were monitored for up to 12 postoperative hours every three hours on the ward. Venous blood samples were taken before intervention and after surgery to evaluate redox homeostasis (levels of malondialdehyde - MDA, nitrogen monoxide, glutathione and sulfhydryl groups and the activity of superoxide dismutase and catalase) and inflammatory parameters (blood count, neutrophile/lymphocyte ratio, C-reactive protein and Interleukin 6). Perioperative complications in the induction phase, intraoperative and postoperative period, as well as the consumption of opioids, were noted. RESULTS: 16 patients in the D and 15 in the N groups participated in the study. There was no difference in age, sex, body weight and duration of surgery between the two groups. The obtained results of oxidative stress and inflammatory response markers showed that there was a statistically significant difference in the MDA level between compared groups (postoperative MDA 88.93 ± 1.19 vs. 95.05 ± 1.58, ΔMDA 0.014), with no difference observed in other investigated oxidative and inflammatory stress in plasma samples. Patients in both groups were hemodynamically and respiratory stable. Still, patients in the treated (D) group achieved the desired level of sedation compared to the control evaluated by the Ramsey sedation score (p < 0.001). The BIS values were statistically significantly different between the D and N groups 30 minutes after inhalation (86.6 ± 11.6 vs. 98.1 ± 1.2, P < 0.001), but showed no differences during and after the procedure. The two groups had a significant difference in pain control upon awakening and one hour after the operation, respectively (pain on awakening p = 0.024; pain during the first hour of stay in the ward p = 0.039). The consumption of intraoperative opioids was slightly lower in the D group than in the N group (D vs. N group: fentanyl in µg/kg mean 3.67 ± 0.78 vs. 3.94 ± 1.12, p = 0.445, i.e., alfentanil in µg/kg mean 2.02 ± 1.85 vs. 2.30 ± 2.08, p = 0.691). Also, there were no differences in observed perioperative complications between groups. CONCLUSION: Inhaled Dexmedetomidine at a dose of 2 µg/kg in premedication reduces oxidative stress. However, the statistical significance of this drugs effect on the level of markers of antioxidant defense and inflammation has not been proven in children operated on for tonsillar hypertrophy. This dose regimen and route of application of Dexmedetomidine significantly affect the degree of perioperative sedation and BIS values, provides perioperative hemodynamic and respiratory stability, significant immediate postoperative analgesia, and reduces the consumption of analgesics with minimal complications, which makes it useful for shorter surgical interventions.
14 May 2026
Read appraisal →Annals of medicine
Ceftriaxone for methicillin-susceptible Staphylococcus aureus bloodstream infections is associated with increased short-term mortality: a systematic review and meta-analysis
BACKGROUND: Bloodstream infections (BSIs) by methicillin-susceptible Staphylococcus aureus (MSSA) are a significant cause of morbidity and mortality, traditionally treated with antistaphylococcal penicillins (ASPs) or cefazolin. Ceftriaxone has emerged as an alternative due to its once-daily dosing regimen and favourable safety profile; however, its efficacy compared to the standard of care (SoC) remains controversial. This evidence synthesis aimed to assess the role of ceftriaxone in treating MSSA-BSIs. METHODS: A systematic literature search was conducted in PubMed, Embase, and Scopus up to December 31, 2025 (PROSPERO protocol CRD42024595748). Studies comparing ceftriaxone to ASPs or cefazolin for MSSA-BSIs were included. Primary outcomes were 30-day and 90-day all-cause mortality . Pooled effect sizes with their 95% confidence intervals (CIs), were calculated using random-effects models, odds ratios (ORs) and mean differences (MDs) according to the type of outcome. RESULTS: Eleven studies totalling 2,568 patients were included. Ceftriaxone was associated with significantly increased 30-day mortality (OR 3.33; 95% CI: 2.17-5.10), although differences at 90 days were not significant (OR 1.71; 95% CI: 0.75-3.90). No significant differences were noted for clinical success (OR 0.49; 95% CI: 0.19-1.26), microbiological clearance (OR 1.66; 95% CI: 0.73-3.82). Adverse event rates were similar between groups. CONCLUSION: Given the availability of various alternatives and the consistent short-term mortality signal observed, routine use of ceftriaxone for MSSA-BSIs, especially as initial therapy, is not supported by current evidence. Only novel findings from randomized studies may change the place in therapy of the drug in this context.
13 May 2026
Read appraisal →PloS one
Systematic evaluation of the DeepSeek large language model for clinical diagnostic reasoning
BACKGROUND: Artificial intelligence (AI) is undergoing an era of transformative advancement, particularly through the emergence of Transformer-based large language models (LLMs). While these systems demonstrate strong reasoning and generalization capabilities, their clinical applicability, particularly in emergency and critical care decision-making, remains underexplored.. In time-sensitive settings, diagnostic reasoning must align rigorously with evidence-based standards and ensure the relevance of timing to clinical decisions. OBJECTIVE: This study aims to provide a preliminary evaluation of the decision-support performance of the DeepSeek model in acute medical scenarios. We systematically evaluate its diagnostic reasoning, temporal consistency of recommendations, and adherence to evidence-based critical care protocols using standardized case-based assessments. METHODS: Twenty-nine representative clinical cases were extracted from the Merck Manual of Diagnosis and Therapy, a widely used medical reference providing standardized case descriptions. The model's outputs were evaluated across four decision-making dimensions: differential diagnosis, diagnostic testing, final diagnosis, and management planning. Human raters scored each response for accuracy, and multivariable linear regression was applied to assess associations between performance and case parameters (age, gender, and Rapid Emergency Medicine Score [REMS]). RESULTS: DeepSeek achieved an overall mean accuracy of 82.9% (95% CI: 80.2-85.6%) across all cases. Accuracy peaked in final diagnosis (97.7%), but declined in differential diagnosis (73.0%). Model performance showed no significant variation across demographic or severity strata. CONCLUSIONS: DeepSeek shows promising performance in structured case-based diagnostic tasks, particularly in confirmatory diagnostic reasoning. However, its early-stage reasoning and handling of ambiguous cases require enhancement. Future studies using larger and more diverse clinical datasets are needed to further evaluate the model's robustness and potential clinical applicability.
13 May 2026
Read appraisal →Signal transduction and targeted therapy
Acute hemodynamic effects of TPN171H in pulmonary arterial hypertension: a randomized, controlled, phase 2a trial
Pulmonary arterial hypertension (PAH) has a poor prognosis despite available treatments. TPN171H, structurally modified from traditional Chinese medicine (Epimedium), was reported to have a high affinity for phosphodiesterase type 5 and exhibited anti-inflammatory and vasodilatory effects in preclinical studies. This phase 2a randomized trial (NCT04483115) evaluated the hemodynamic effects and safety of TPN171H in PAH. Sixty patients with PAH were randomly assigned to receive placebo, TPN171H (2.5, 5, or 10 mg) or tadalafil (20 or 40 mg) and evaluated for hemodynamic changes for 24 h. The primary endpoint was the maximum change (%) in pulmonary vascular resistance (PVR) from baseline. The key secondary endpoint was the change (%) in PVR to systemic vascular resistance (SVR) ratio at each observation point from baseline. Compared to the placebo group, the least square mean differences in the maximum change in PVR were -16.8% (95% CI, -29.1 to -4.5, p = 0.008) in TPN171H 5 mg, -15.4% (95% CI, -28.2 to -2.7, p = 0.019) in tadalafil 20 mg, and -13.3% (95% CI, -25.6 to -0.9, p = 0.036) in the tadalafil 40 mg group. Moreover, TPN171H 5 mg, but none of the tadalafil doses, showed a significant reduction in PVR/SVR ratio at 2 h (p = 0.026), 3 h (p = 0.030), and 5 h (p = 0.046) compared to the placebo group. No serious adverse events occurred. TPN171H 5 mg demonstrated favorable acute hemodynamic effects and an acceptable short-term safety profile in this exploratory trial, supporting further evaluation in adequately powered trials.
11 May 2026
Read appraisal →Journal of burn care & research : official publication of the American Burn Association
Hyperbaric Oxygen Therapy in Burn Care: A Systematic Review of Current Evidence
Hyperbaric oxygen therapy (HBOT) involves inhaling 100% oxygen at pressures exceeding one atmosphere within a chamber. It is used across several specialties and has been proposed as an adjunct in burn management to enhance healing and improve outcomes. Despite increasing interest, evidence supporting its efficacy in burn care remains inconsistent, with no clear consensus in practice. A literature search was conducted in September 2025 across PubMed, Cochrane Library, and Embase without date restrictions to identify studies evaluating HBOT for burn treatment. Inclusion criteria were human studies, English-language articles, and full-text availability. Study selection followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers screened titles and abstracts, and a third resolved discrepancies. Eligible studies described HBOT as a burn treatment and reported clinical outcomes. Thirteen studies met inclusion criteria: 5 randomized controlled trials, 7 cohort studies, and 1 case-control study, evaluating 566 burn patients. Burn severity, HBOT protocols, and outcomes varied substantially. Several studies reported reduced need for surgery and shorter hospital stays with HBOT. Trends toward improved healing and lower infection risk were noted, while mortality benefits were inconsistent. Heterogeneity in design and treatment regimens limited synthesis via meta-analysis. Hyperbaric oxygen therapy shows promise as an adjunct in burn care, improving healing and reducing complications. However, variability and inconsistent outcomes limit definitive conclusions. Well-designed randomized trials are needed to establish standardized protocols and clarify their clinical role in burn management. Until then, burn centers may consider HBOT for acute injuries and threatened grafts.
11 May 2026
Read appraisal →Journal of burn care & research : official publication of the American Burn Association
FGF2 in Burn Wound Healing: From Molecular Function to Clinical Application-A Systematic Review
Burn injuries trigger complex inflammatory and metabolic cascades that impair wound healing and increase morbidity. Fibroblast growth factor 2 (FGF2), a potent mediator of cellular proliferation, angiogenesis, and extracellular matrix remodeling, has emerged as a promising therapeutic agent in burn care. This systematic review evaluated the biological mechanisms, delivery strategies, and clinical outcomes associated with FGF2 in burn wound healing to clarify its therapeutic value and translational potential. Following PRISMA 2020 standards, a structured literature search was conducted across PubMed, EMBASE, Web of Science, Cochrane, and Google Scholar to identify studies investigating FGF2 in thermal injuries. Eligible records included clinical trials, in vivo models, and in vitro experiments. Methodological quality and risk of bias were assessed using the Newcastle-Ottawa Scale, the SYRCLE tool, and the Oxford Levels of Evidence. Thirty-three studies (1992-2025) met inclusion criteria, encompassing randomized controlled trials, animal models, and mechanistic analyses. Fibroblast growth factor 2 accelerated repair by stimulating fibroblast proliferation, keratinocyte migration, angiogenesis, and matrix organization. Topical FGF2 formulations shortened healing time and improved scar quality in partial-thickness burns. Innovative carriers, including hydrogels, liposomes, and gene-activated matrices, enhanced bioavailability and sustained local effects. In diabetic and complex burn models, FGF2 mitigated inflammation, preserved barrier integrity, and promoted re-epithelialization. Efficacy depended on dosage and wound characteristics. Studies reported favorable safety profiles with minimal and mild adverse events. Fibroblast growth factor 2 demonstrates regenerative and immunomodulatory potential in burn management. Broader adoption requires harmonized regulatory evaluation, optimized delivery systems, and multicenter validation to define its role in precision-guided burn care.
11 May 2026
Read appraisal →Biomaterials science
Hydrogel-based wearable and implantable biosensors in health monitoring.
Hydrogel-based wearable and implantable biosensors have quickly established themselves as a paradigm-shifting platform for continuous health monitoring. They effectively reconcile the mechanical and chemical discrepancies between conventional rigid electronics and delicate biological tissues. This success is largely attributed to the hydrogel material's inherent advantages: high water content, a precisely tunable elastic modulus, and versatile functional chemistry. Collectively, these features provide structural, biological, and processing benefits that facilitate truly seamless bioelectronic integration. This Review systematically summarizes the latest advancements in hydrogel biosensors, placing emphasis on their distinctive material attributes. These include the synergistic ionic-electronic conduction, sensitive stimuli responsiveness, advanced antifouling surface chemistry, and exceptional tissue-mimicking compliance. We further delve into the fundamental physical and chemical sensing mechanisms, supported by representative applications spanning from the non-invasive, real-time analysis of sweat, tears, saliva, and interstitial fluids to the more complex domains of subcutaneous, cardiac, and neural implants. Finally, we candidly address the crucial hurdles that remain, such as long-term hydration stability, signal fidelity drift, and adverse immune responses. Concurrently, we highlight pioneering strategies to overcome these issues, including the adoption of zwitterionic designs for enhanced biocompatibility, nanocomposite reinforcement for mechanical robustness, and the utilization of transient biodegradability. By critically elucidating the intricate relationships governing hydrogel structure, chemistry, and bioelectronic function, this Review aims to chart the research trajectory toward the next generation of durable, self-healing, and fully biointegrated sensing systems.
11 May 2026
Read appraisal →Journal of burn care & research : official publication of the American Burn Association
Metabolic and Immunomodulatory Effects of α-Ketoglutarate in Burn Injuries: A Systematic Review
Severe burns unleash a hyper-catabolic and immunosuppressive state that erodes lean tissue and delays repair. Alpha-ketoglutarate (α-KG), usually delivered enterally as the dipeptide ornithine α-ketoglutarate (OKG), feeds the tricarboxylic-acid cycle, donates nitrogen for amino-acid synthesis, and modulates collagen formation and immunity. We systematically appraised the biological mechanisms, delivery strategies, and clinical outcomes associated with α-KG/OKG in burn care to clarify its therapeutic value and translational readiness. A PRISMA-2020-compliant search of PubMed, EMBASE, Web of Science, Cochrane, and Google Scholar up to May 2025 identified clinical, in vivo, and relevant in vitro studies linking α-KG or OKG with thermal injury. Study quality was assessed using the Newcastle-Ottawa Scale, SYRCLE Risk-of-Bias tool, and Oxford Levels of Evidence. Fifteen studies published between 1984 and 2024 met inclusion criteria, including clinical, animal, and mechanistic work, most conducted in France. Across studies, OKG supplementation replenished glutamine and arginine pools, improved nitrogen balance, preserved muscle mass, and promoted wound healing through enhanced collagen synthesis and immune modulation. Clinical data confirmed improved nitrogen retention, reduced muscle breakdown, and faster wound closure. Preclinical studies further showed that α-KG preconditioning enhances stem cell-driven regeneration and vascularization. Additional effects, such as improved glucose tolerance and hepatic enzyme preservation, suggest some benefits occur independently of glutamine pathways. This review highlights α-KG and OKG as promising adjuncts to enhance metabolic recovery, wound repair, and immune competence after burns. Evidence supports improved nitrogen balance and healing, but findings remain limited by heterogeneity and small cohorts, warranting renewed and well-powered studies.
11 May 2026
Read appraisal →PloS one
Association between hemoglobin dynamic trajectories and 28-day mortality in elderly patients with sepsis: A retrospective cohort study using the MIMIC-IV database
BACKGROUND: Anemia is a common complication in sepsis and is associated with poor prognosis. However, there are few studies on the dynamic changes in hemoglobin (Hb) levels and their relationship with prognosis in elderly patients with sepsis. This study aims to retrospectively investigate the relationship between Hb trajectories and 28-day mortality in this population. METHODS: This retrospective observational study used data from 4,961 elderly patients with sepsis extracted from the MIMIC-IV database(2008-2019). Hb trajectories were identified using a Joint Latent Class Model (JLCM) for longitudinal pattern classification. Following validation of proportional hazards assumptions (Schoenfeld residual test), we assessed the prognostic relationship between Hb trajectories and 28-day mortality using multivariable Cox regression models and Kaplan-Meier survival curves. Sensitivity analyses included sex-stratified multivariable Cox regression, subgroup analysis, and E-value assessment. RESULTS: Hb trajectories were classified into three patterns: Class 1 with persistently low levels, Class 2 with medium levels and a gradual decline, and Class 3 with a rapid decline from higher levels. Using Class 2 as the reference, multivariable Cox regression showed that Class 1 (HR = 1.38, 95% CI = 1.18-1.62, p < 0.001) and Class 3 (HR = 1.21, 95% CI = 1.03-1.42, p = 0.020) were associated with higher 28-day mortality. Kaplan-Meier curves indicated the lowest survival probability in Class 1 and the highest in Class 2. Gender-specific analysis revealed consistent trajectory patterns between males and females, but higher Hb values in males. The predictive power of the rapid decline pattern for early mortality was stronger in males. CONCLUSION: The Hb trajectories in elderly sepsis patients are significantly associated with early mortality. Persistently low levels and rapid declines in Hb are indicators of poor prognosis.
10 May 2026
Read appraisal →Palliative & supportive care
Definitional confusion in nurses' and physicians' attitudes toward euthanasia in India: A systematic review and meta-analysis
INTRODUCTION: In India, the term euthanasia is frequently used to describe a wide range of end-of-life practices, including withdrawal of life-sustaining treatment and administration of lethal drugs. Such usage diverges from more narrow definitions that restrict euthanasia to the intentional administration of lethal drugs. OBJECTIVES AND SIGNIFICANCE OF THE RESULTS: This systematic review and meta-analysis examines how euthanasia has been defined and operationalized in quantitative studies of Indian physicians' and nurses' attitudes, and estimates the prevalence of approval when euthanasia is defined narrowly. METHODS: Following PRISMA 2020 guidelines, searches were conducted in PubMed, EMBASE, PsycINFO, and CINAHL for studies published from 2010 onward. Two investigators independently screened studies, extracted data, and assessed risk of bias using the Mixed Methods Appraisal Tool (MMAT). Studies were included in the meta-analysis only if they reported attitudes toward euthanasia as narrowly defined. RESULTS: Nine studies met inclusion criteria for the systematic review. Definitions of euthanasia varied considerably, and several studies combined attitudes toward treatment withdrawal with attitudes toward the administration of lethal drugs. Four studies reporting on 519 nurses and physicians provided data suitable for meta-analysis. Approval of euthanasia, defined as the intentional administration of lethal drugs, ranged from 12% to 20%, with a pooled prevalence of 16% (95% confidence interval: 0.13-0.19). This prevalence is notably lower than in earlier reports on Indian healthcare professionals' attitudes. CONCLUSION: Definitional inconsistency substantially affects reported attitudes toward euthanasia in Indian research. When euthanasia is defined narrowly, approval among healthcare professionals is low and consistent across studies. These findings highlight the need for conceptual clarity in future research to support accurate interpretation of empirical data and to strengthen the contribution of studies on ethical attitudes to ethical and palliative care scholarship.
10 May 2026
Read appraisal →European journal of pediatrics
Impact of protocolized restrictive versus liberal/usual maintenance fluid strategy on fluid overload among mechanically ventilated children: an open-label randomized trial (ReLiSCh-II trial)
UNLABELLED: Fluid overload (FO) is associated with poor clinical outcomes among critically ill children. The objective of this trial was to assess the impact of a protocolized restrictive maintenance fluid strategy on FO among mechanically ventilated children. This open-label randomized controlled trial was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital in North India over 13 months (November 2023-November 2024). Hemodynamically stable mechanically ventilated children were randomized to protocolized restrictive (n = 64) (40-50% of maintenance fluids with diuretic infusion if FO% > 10%); and liberal/usual (n = 66) (70-80% of maintenance fluid) groups. The primary outcome was the proportion of children with cumulative FO% > 10% through day 5. Secondary outcomes were daily cumulative FO%; inferior vena cava variability index (∆IVC) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at 48 h; safety parameters (requirement of fluid boluses or vasoactive drugs); 28-day ventilator and PICU-free days (VFDs and PFDs), and mortality. Significantly fewer children in the protocolized restrictive group had cumulative FO% > 10% than in the liberal/usual group (22% vs. 47%, p = 0.003). Also, the restrictive group had significantly lower daily cumulative FO% on the first 5 days. ∆IVC and NT-proBNP levels at 48 h, as well as safety parameters, were similar between the two groups. Protocolized restrictive and liberal/usual groups had similar VFDs [20 (8-24) vs. 16 (0-23), p = 0.076], PFDs [16 (3-21) vs. 13 (0-19), p = 0.071], and mortality (14% vs. 24%, p = 0.14). CONCLUSION: A protocolized restrictive maintenance fluid strategy resulted in significantly lower FO among hemodynamically stable, mechanically ventilated children without a measurable impact on short-term clinical outcomes. WHAT IS KNOWN: • Fluid overload (FO) is associated with poor clinical outcomes among critically ill mechanically ventilated children. WHAT IS NEW: • Among hemodynamically stable, mechanically ventilated children, a restrictive maintenance fluid strategy may be a useful intervention to limit FO and improve clinical outcomes in LMICs.
10 May 2026
Read appraisal →Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation
Quality of life after tranexamic acid in subarachnoid hemorrhage: post-hoc analysis of the ULTRA trial
PURPOSE: The ULTRA trial evaluated the impact of ultra-early and short-term tranexamic acid (TXA) treatment in patients with subarachnoid hemorrhage (SAH) and found no clinical benefit at six months. This post-hoc analysis examines whether TXA improves quality of life (QoL) at three and six months. METHODS: The ULTRA trial was a randomized, controlled, multicenter study conducted from July 2013 to July 2019. Patients received either TXA or standard care. This analysis included patients who completed at least one QoL questionnaire. The primary endpoint was QoL, assessed using the EQ-5D-3L questionnaire at three and six months. Linear mixed models adjusted for confounders were used to analyze the association between TXA and QoL. RESULTS: Of the 955 ULTRA patients, approximately 25% died, and 63% completed at least one QoL questionnaire. At three months, the TXA group had a mean EQ-5D index score of 0.75 versus 0.71 in the control group (p = 0.11) and a mean EQ-5D Visual Analogue Scale (VAS) score of 89 versus 86 (p = 0.10). At six months, the mean EQ-5D index score was 0.84 in the TXA group compared to 0.82 in the control group (p = 0.23), and the mean VAS was 92 in the TXA group compared to 89 in the control group (p = 0.13). CONCLUSION: Ultra-early and short-term TXA did not result in a significant improvement in QoL at three or six months in patients with SAH. Given the lack of benefit on both clinical outcome and QoL, routine use of TXA is not recommended. TRIAL REGISTRATION: Netherlands Trial Register: NTR3272. CLINICALTRIALS: gov: NCT02684812.
10 May 2026
Read appraisal →Asian journal of psychiatry
Machine learning prediction model for delirium after heart valve replacement with cardiopulmonary bypass: A large-scale cohort study
OBJECTIVE: Postoperative delirium (POD) is a common and severe complication following heart valve replacement (HVR) with cardiopulmonary bypass (CPB), associated with poor outcomes. Accurate early prediction is crucial for targeted prevention. This study aimed to develop and externally validate machine learning (ML) models for predicting POD in this high-risk population. METHODS: We conducted a retrospective cohort study involving 1076 adult patients who underwent HVR with CPB between January 2018 and December 2022. POD was assessed using the CAM-ICU. Perioperative factors were analyzed to develop a traditional logistic regression-based nomogram and four ML models. The best-performing model was then tested on an independent external validation cohort of 281 patients. RESULTS: The incidence of POD was 25.1% (270/1076) and was associated with significantly increased mortality (11.9% vs. 0.2%, P < 0.001) and prolonged hospitalization. In the internal test set, the Random Forest (RF) model demonstrated the highest predictive performance with an AUROC of 0.854 (95% CI, 0.764-0.945), outperforming the traditional nomogram (AUROC: 0.754). The RF model maintained robust performance in the external validation cohort, achieving an AUROC of 0.793. Model interpretation using SHAP analysis identified postoperative awakening time (PAT), postoperative mechanical ventilation time (PMVT), and postoperative reintubation (POR) as the most influential predictors. CONCLUSIONS: Machine learning models, particularly Random Forest, provide a robust and generalizable tool for the early prediction of POD after HVR. These models outperform traditional statistical approaches and offer interpretable insights, highlighting PAT as a critical, modifiable target for perioperative management to mitigate POD risk.
9 May 2026
Read appraisal →Annual review of biomedical engineering
Digital Twins for Biofluids
Digital twins-virtual representations dynamically linked to physical systems-have the potential to transform biomedical engineering by enabling real-time prediction, optimization, and personalization in health and disease. In biofluids, digital twins offer a framework for integrating physics-based models with data from clinical imaging, sensors, and physiological measurements to support diagnostics, therapeutic planning, and device design. This article reviews modeling approaches used in the construction of digital twins for biofluid applications. We survey high-fidelity numerical methods alongside emerging machine learning techniques, highlighting their respective strengths and limitations. Key requirements for digital twins are discussed, emphasizing the bidirectional interaction between physical and virtual assets and the importance of selecting modeling strategies tailored to specific biomedical contexts. While notable progress has been made over the past decade, significant challenges remain, particularly in integrating multiphysics models with data-driven methods and in establishing standardized protocols for data acquisition, interoperability, and sharing.
5 May 2026
Read appraisal →Journal of medical systems
Automated data extraction from electronic medical records for pragmatic clinical trials
Data collection in randomized trials is expensive and labor intensive. With the rise in ongoing pragmatic trials, the use of electronic medical records (EMR) as a source of data has increased. Although potentially faster and cheaper, EMR use can lead to errors. Therefore, to ensure accurate data collection and to avoid systematic errors we performed a study comparing automated data extraction (ADE) with manual data extraction (MDE). We performed a retrospective cohort study to compare the accuracy of ADE using Structured Query Language with MDE by blinded physicians from our EMR. We tested the interrater agreement and intraclass correlation coefficient of clinical baseline data and outcomes of a random sample of 30 patients admitted to the ICU, on mechanical ventilation, requiring opioids for analgosedation for an upcoming pragmatic clinical trial. Key data compared included, but not limited to, patient's demographics, laboratory and vital signs, daily morphine milligram equivalent (MME), days alive and free of mechanical ventilation, days alive and free of hospitalization, days alive and free of ICU, days alive and free of vasopressors, and death. Among 238 patients screened over 1-month period, 72 fulfilled inclusion criteria and 30 were randomly selected to be included in the evaluation. We blindly collected 1320 baseline data, 2160 categorical outcomes and 705 continuous outcomes for a total of 4185 data points. The intraclass correlation coefficient and the Cohen's Kappa were perfect or almost perfect for all data, including outcomes such as daily MME, days alive and free of mechanical ventilation, days alive and free of ICU and days alive and free of hospital with p < 0.001. Among all rechecked data, the ADE was correct in 53 (77.9%) of cases, while MDE in 15 (22.1%). The inaccurate data collected by ADE accounted for 0.36% of the total data-points. The performance of ADE had almost perfect agreement for all outcomes and when rechecking for disagreements, it was more accurate than MDE.
5 May 2026
Read appraisal →Journal of the American College of Surgeons
In-Hospital Mortality Prediction of Patients Requiring Extracorporeal Membrane Oxygenation Using Composite Lactate Metrics and Weight-of-Evidence Modeling
BACKGROUND: Mortality prognostication in adult patients requiring extracorporeal membrane oxygenation (ECMO) is not accurate or established. We hypothesized that composite lactate-based metrics and machine-learning models would improve in-hospital mortality prognostication compared with lactate alone in this population. STUDY DESIGN: We conducted a retrospective study of adult patients supported with ECMO at a Level I trauma center from 2022 to 2024 (N = 104). Composite metrics were generated by multiplying lactate by acid-base markers and comparing performance to lactate after Benjamini-Hochberg correction to control the false discovery rate. For machine-learning models, 3 multilayer perceptron architectures were developed using laboratory markers from a patient's hospital admission. Feature attribution through local interpretable model-agnostic explanations guided the development of a weight-of-evidence (WoE) model using only initial laboratory values. RESULTS: The composite metric of average arterial lactate × average arterial bicarbonate was the most significantly elevated marker in nonsurvivors and more significant than lactate alone (false discovery rate-adjusted p = 4.49 × 10 -4 vs 2.14 × 10 -3 ). The 100 × 50 multilayer perceptron architecture achieved 85% accuracy (95% CI 80 to 89%), 87% precision (95% CI 82% to 92%), F1 score of 0.81 (95% CI 0.74 to 0.86), and area under the curve of 0.879 (95% CI 0.84 to 0.92). Local interpretable model-agnostic explanations identified kidney replacement therapy, surrogate respiratory quotient, lactate gradient, and arterial bicarbonate as metrics incorporated in the WoE model achieving 80% accuracy (95% CI 76% to 84%), 70% precision (95% CI 63% to 77%), F1 score of 0.72 (95% CI 0.66 to 0.78), and area under the curve of 0.886 (95% CI 0.853 to 0.920). CONCLUSIONS: Composite lactate metrics and the WoE model improved in-hospital mortality prediction in patients requiring ECMO. Prospective studies and external validation are warranted to confirm these findings.
4 May 2026
Read appraisal →European journal of pediatrics
Evaluating the impact of simulation on patient outcomes in pediatric and neonatal critical care: a systematic review and critical appraisal of the evidence
UNLABELLED: While the literature widely supports a positive relationship between simulation-based education (SBE) and learning outcomes, its impact on patient outcomes remains less clearly understood. Our aim was to comprehensively survey the landscape of simulation-based research (SBR) that evaluates patient outcomes (Kirkpatrick Level 4) in the context of pediatric and neonatal critical care. A systematic search of MEDLINE, Cochrane Library, CINAHL, and ERIC was conducted through December 2024. We included RCTs, non-RCTs, and before-after studies focusing on Kirkpatrick Level 4 outcomes. Quality was appraised using the RoB 2 and ROBINS-I tools. A total of 2481 articles were screened. Sixteen studies met the inclusion criteria. Most were prospective (63%) and single-center (69%), with only three RCTs (19%). All included studies (100%) reported Level 4 outcomes; however, a critical distinction emerged between system-level and patient-level results. While 75% (12/16) of studies reported positive impacts on Level 4a (system processes), such as protocol adherence or response times, only 50% (8/16) demonstrated significant improvements in Level 4b (direct patient outcomes), such as mortality or complication rates. In addition, all included studies were judged to have a high or critical risk of bias. CONCLUSIONS: Although SBE effectively optimizes clinical processes (Level 4a), a significant evidence gap remains regarding its direct impact on patient health (Level 4b). Current SBR often lacks the methodological rigor-specifically the use of randomized designs-needed to isolate SBE as the primary driver of clinical improvement. Future research must prioritize high-quality, multicenter trials targeting patient-oriented metrics to bridge this translational gap. WHAT IS KNOWN: • SBE has been extensively developed in pediatric and neonatal critical care settings; however, its impact on healthcare professional training and on patient outcomes remains less well understood. WHAT IS NEW: • There is a scarcity of rigorous Level 4 evidence linking SBE to patient outcomes in pediatric and neonatal critical care. • We provide a methodological roadmap advocating for mixed-methods and multicenter designs to bridge this clinical evidence gap.
1 May 2026
Read appraisal →Biomedizinische Technik. Biomedical engineering
Evaluation of an adaptive system for breathing control in closed-loop diaphragm pacing
OBJECTIVES: Existing diaphragm pacing (DP) system use an open-loop control method with a fixed stimulation mode to control breathing. It requires doctors to manually adjust stimulation parameters to meet the patient's ventilation needs. METHODS: A neural network adaptive controller was tested to control breathing in DP system. For the diaphragm motion model, the respiratory airflow of healthy adults and rabbits was collected and compared with the simulation calculation results to verify the accuracy of the model. The performance of the adaptive controller was evaluated comparatively with that of the PID controller. Adaptive controller consists of a neural network and adaptively adjusts stimulation parameters to produce the desired respiratory volume waveform. Superiority of the output performance of the adaptive controller was further studied by setting various diaphragm model parameters. We further verified the feasibility of the adaptive controller through animal testing. RESULTS: The adaptive controller is better than the PID controller in maintaining the stability of the desired breath volume. Application of the adaptive controller can reduce the root mean square (RMS) error between the desired breath volume and the actual value to less than 6 %. CONCLUSIONS: This study demonstrates the potential application of adaptive controllers in closed-loop DP systems.
27 Apr 2026
Read appraisal →Heart (British Cardiac Society)
Variation in mechanical circulatory support use for acute myocardial infarction cardiogenic shock
BACKGROUND: Cardiogenic shock (CS) is a leading cause of mortality following acute myocardial infarction (AMI). Some patients may require intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (PVAD) placement; however, there is a paucity of standardised algorithms to guide the deployment of each device. The present study evaluated interhospital variation in the use of IABP and PVAD for AMI CS and identified institutional factors associated with hospital-level device preference. METHODS: All non-elective adult hospitalisations entailing AMI and CS were identified within the 2019 Nationwide Readmissions Database. Patients were grouped into IABP, PVAD and non-mechanical circulatory support cohorts. The primary aim was to quantify the degree of interhospital variation in the use of IABP and PVAD. Escalation to extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD) implantation, length of stay and hospitalisation costs were secondarily assessed. Hospital factors, such as percutaneous coronary intervention (PCI) volume and safety net status, were also analysed. RESULTS: Among 53 903 patients, 23.4% received IABP, and 12.5% received PVAD. After adjustment for patient factors, approximately 13% (11-14%) of variation in IABP use and 18% (15-20%) of PVAD use were attributable to centre-level differences. High-PVAD hospitals had higher annual PCI volume (257 (185-369) vs 204 (148-276) cases/year, p=0.032) and were more commonly safety net institutions (27.4% vs 11.3%, p=0.023), compared to high-IABP hospitals. Patients treated at high-IABP and high-PVAD hospitals faced similar length of stay (β -0.16, 95% CI -1.82 to 1.49) and costs (β -$3500, 95% CI -16 600 to 9600). Those at high-PVAD hospitals had lower adjusted risk of escalation to ECMO (0.52, 95% CI 0.29 to 0.95) and LVAD implantation (0.28, 95% CI 0.08 to 0.94). CONCLUSIONS: The present study identified wide interhospital variation in the use of IABP and PVAD for AMI CS. Although the likelihood of escalation to ECMO or LVAD differed between hospital types, resource utilisation was similar.
27 Apr 2026
Read appraisal →Renal failure
Explainable machine learning using urinary metabolomics to predict pediatric sepsis-associated acute kidney injury: a two-center prospective observational study
Sepsis-induced acute kidney injury (S-AKI) is a common and serious complication in critically ill children with a poor prognosis, and its early and accurate prediction remains challenging due to the lack of reliable biomarkers. Urinary small-molecule metabolomics offers a promising approach to capture the dynamic metabolic changes during the progression of S-AKI. In this two-center prospective observational study, we enrolled 360 children from both centers. Urine samples were collected within 24h after hospitalized children diagnosed with sepsis, stored at -80 °C, and analyzed using gas chromatography-mass spectrometry (GC-MS). Based on urinary metabolic fingerprints (U-MF), we developed and validated a machine learning model for early prediction of S-AKI. The Shapley Additive Explanations (SHAP) algorithm was applied to visually explain the optimal model. A panel of 10 metabolites was selected as common discriminative features. Among the 4 machine learning models evaluated, the support vector machine (SVM) demonstrated the best performance in both the discovery cohort (AUC 0.94, 95% CI: 0.91-0.98) and the external validation cohort (AUC 0.89, 95% CI: 0.82-0.96), enabling early prediction of S-AKI within 24 h. Furthermore, the U-MF panel was integrated into an open-access online platform to facilitate clinical translation. Our findings suggest that U-MF combined with machine learning holds promise as a robust and noninvasive approach with potential utility for early prediction of S-AKI in pediatric patients.
24 Apr 2026
Read appraisal →PloS one
Artificial intelligence for monitoring hand hygiene compliance in healthcare settings: A scoping review
BACKGROUND: Hand hygiene is a fundamental measure for preventing healthcare-associated infections, yet traditional monitoring methods are significantly limited by the Hawthorne effect, high resource demands, and an inability to assess procedural quality. Artificial intelligence (AI) technology has emerged as a transformative, automated, and objective approach to address these long-standing challenges. OBJECTIVE: This scoping review sought to systematically map the existing evidence, technical pathways, performance metrics, and implementation challenges of AI for monitoring hand hygiene compliance in healthcare settings. METHODS: Following the Joanna Briggs Institute (JBI) methodological framework and PRISMA-ScR guidelines, we searched five major databases (PubMed, Scopus, Embase, Web of Science, and IEEE Xplore) for articles published between January 2000 and September 2025, supplemented by grey literature searching and backward citation tracking. Two reviewers independently screened records, assessed full-text reports for eligibility, and extracted data, which were synthesized using descriptive statistics and thematic analysis. RESULTS: Of 800 records identified through database and supplementary searches, 45 studies (2007-2025) were included. The primary technical pathways identified were computer vision (53.3%), wearable sensors (24.4%), Internet of Things-integrated systems (13.3%), and radar/radio frequency-based systems (8.9%). While computer vision achieved high accuracy (95%) in setting-specific ICU models, performance dropped to 56% in generalizable models. Wearable systems demonstrated portability but showed 5%-10% lower specificity than vision-based approaches. Most evidence is derived from small-scale technical validations, with a significant lack of formal fairness analysis and evaluation of clinical workflows or cost-effectiveness. CONCLUSION: AI-based hand hygiene monitoring shows promise for supporting more objective and scalable hand hygiene surveillance in healthcare settings. However, the field remains at a largely pre-translational stage. Future research should shift from technical feasibility toward implementation science, focusing on establishing standardized motion databases, evaluating ethical governance (e.g., privacy and automation bias), and conducting pragmatic trials to demonstrate sustained clinical benefit and organizational sustainability.
24 Apr 2026
Read appraisal →The Cochrane database of systematic reviews
Lung transplant in people with cystic fibrosis and nontuberculous mycobacteria infection
RATIONALE: Cystic fibrosis (CF) is an inherited multi-organ disorder. People with CF (pwCF) experience recurrent and chronic lung infections and a progressive loss of lung function. PwCF with poor and rapidly declining lung function may be considered for lung transplantation (LTx), which may improve their quality of life and survival. Nontuberculous mycobacteria (NTM) can cause pulmonary disease in pwCF, and NTM infection is a poor prognostic factor in LTx. Guidelines recommend NTM infection should not automatically preclude LTx. It is important to evaluate the evidence base for LTx in pwCF and NTM pulmonary disease. OBJECTIVES: To evaluate clinical outcomes in pwCF and with NTM infection (NTM infection alone or with NTM pulmonary disease) who undergo LTx by comparing: 1. pwCF with current NTM lung infection who undergo LTx versus those with NTM infection who do not undergo LTX; 2. pwCF with current NTM lung infection who undergo LTx versus those without NTM undergoing LTx. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis Trials Register, CENTRAL, MEDLINE, Embase, and PubMed as well as two ongoing trials registries. We checked references. The latest search date was 17 February 2026. ELIGIBILITY CRITERIA: We considered non-randomised studies of pwCF (any age) with or without NTM lung infection or disease being considered for LTx as well as studies of pwCF and NTM who either did or did not undergo LTx. OUTCOMES: Our critical outcomes were mortality, disseminated NTM infection post-LTx, time to chronic lung allograft dysfunction (CLAD), and quality of life at any time points reported. We additionally planned to report lung function, hospitalisations for pulmonary exacerbations, and nutritional parameters in the review. RISK OF BIAS: We assessed the risk of bias in three studies using ROBINS-I and in one study using the Joanna Briggs Institute checklist for case series. SYNTHESIS METHODS: We could only report results narratively. We used GRADE to assess the certainty of the evidence. INCLUDED STUDIES: We included four single-centre retrospective studies (388 adults). Sample sizes ranged from nine to 177 participants. Mycobacteria abscessus was the most common NTM species identified, and all studies reported infection with other pathogens. All studies compared pwCF and NTM infection to pwCF without NTM infection, all undergoing LTx. Each study reported mortality and disseminated NTM infection post-LTx; two studies recorded CLAD. No study reported quality of life, specific lung function measures (although one study commented briefly on lung function in general), hospitalisations for pulmonary exacerbations, or nutritional parameters. SYNTHESIS OF RESULTS: We analysed all NTM infections together for practical reasons and were not able to undertake a planned subgroup analysis by subspecies, but acknowledge that the prognosis and clinical trajectory of pwCF infected with different NTM may not be similar. We downgraded the certainty of the evidence due to non-randomised study design and serious risk of bias across all studies. We assessed all identified evidence as of very low certainty, such that lung transplant may have little to no effect on any of the outcomes listed below, but the evidence is very uncertain. Mortality Two studies (18 participants with NTM) reported similar survival data between NTM-positive LTx recipients and matched controls without NTM. Another study (9 participants) reported that two of five participants NTM-positive at LTx died within a few months post-LTx, whilst one of four NTM-negative participants died three years post-LTx due to chronic rejection. One study (177 participants) found that pwCF who had positive NTM cultures pre-LTx had a longer median survival duration than those who had negative cultures. This study additionally reported on survival of participants with post-LTx NTM infection, finding that the five participants who had post-LTx NTM disease had a longer mean survival duration than the 141 participants without post-LTx NTM disease. Disseminated NTM infection post-LTx In the largest study, of the 18 pwCF with NTM at the time of LTx, seven had at least one positive NTM culture, and four developed NTM disease post-LTx. Conversely, 79 of the 89 pwCF without NTM remained so post-LTx; 10 participants recorded a positive NTM culture, but none developed NTM disease. For the 39 participants without a baseline NTM culture, three participants recorded positive NTM cultures post-LTx, and one developed NTM disease. Of the remaining small studies, one reported that NTM was isolated in four of 13 participants at LTx and in three of these post-LTx. A second study reported that one out of five pwCF had NTM infection post-LTx (all were positive at LTx). The third study reported that five out of nine participants had NTM disease at LTx, and two of these five remained NTM-positive post-LTx. CLAD Two studies assessed CLAD. One study reported that none of the five NTM-positive LTx recipients developed CLAD, stating that the risk of CLAD appeared to be similar between the NTM and the comparator group. The second study stated that three out of nine LTx recipients with NTM disease developed chronic rejection or graft dysfunction. AUTHORS' CONCLUSIONS: There are no randomised trials to guide clinicians and patients or their families when making decisions regarding LTx in pwCF with NTM. The available data come from observational studies and registry data, often with few people with NTM reported. It has not been possible to pool the available data in meta-analysis, and we are very uncertain of the effect of NTM on pwCF undergoing LTx on the risk of developing NTM disease post-LTx, survival after LTx, and the development of CLAD. The studies were small and at times contradictory. In the era of highly effective modulator treatments, as some centres do not offer LTx to people with a history of NTM, there is an urgent need for more data to guide decision-making. FUNDING: This review is part of a suite of reviews on NTM funded jointly by the CF Foundation and the CF Trust. REGISTRATION: Protocol registration (2024): www.crd.york.ac.uk/PROSPERO/view/562682.
23 Apr 2026
Read appraisal →Journal of Korean medical science
Comparison of Clinical and Radiological Outcomes Between Suction Aspiration and Combination Methods of Mechanical Thrombectomy in Patients With Acute Cerebral Infarction: The COMPETE Trial
BACKGROUND: Recent advances in suction catheter technology suggest that suction aspiration may prevent thrombus fragmentation during mechanical thrombectomy. We therefore hypothesize that the radiological outcomes of suction aspiration as a first-line treatment would not be inferior to those of the combination technique. This study aims to evaluate the radiological and clinical outcomes of first-line suction aspiration compared with those of the first-line combination technique for large artery occlusion amenable to both modalities. METHODS: The COMPETE trial is a prospective, randomized, multicenter, noninferiority, open-label trial. A total of 1,136 patients will be randomized at a 1:1 ratio to either the suction aspiration or combination technique groups. RESULTS: The primary endpoints are successful recanalization (modified Thrombolysis in Cerebral Infarction scale score ≥ 2b) and a good clinical outcome (modified Rankin Scale score of 0-2) at 90 days after thrombectomy. The technical outcome is the switching rate from the combination technique to suction aspiration and from suction aspiration to the combination technique. The safety outcomes include procedural morbidity, nonprocedural morbidity, procedural mortality, and nonprocedural mortality. CONCLUSION: The COMPETE trial is expected to determine whether the use of suction aspiration as a first-line approach in patients with acute ischemic stroke is noninferior to the combination technique in achieving successful radiological and good clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06254755; CRIS (KCT0007726).
23 Apr 2026
Read appraisal →PloS one
Hybrid feature-selection and diversity-guided stacking framework for interpretable ensemble learning: Application to COVID-19 mortality prediction
BACKGROUND: Reliable predictive modeling in high-dimensional biomedical data requires a balance between accuracy, interpretability, and computational efficiency. However, existing ensemble methods often overlook model diversity or rely on ad hoc feature-selection approaches, which limit generalizability. This study introduces a hybrid feature-selection and diversity-guided stacking framework designed to improve robustness and scalability across clinical and other data-intensive domains. METHODS: The proposed framework integrates a hybrid feature-selection pipeline-combining Variance Inflation Factor (VIF), Analysis of Variance (ANOVA), Sequential Backward Elimination (SBE), and Lasso regression-to reduce multicollinearity and overfitting. It also employs a diversity-aware stacking strategy that constructs sub-model sets based on pairwise diversity measures (Disagreement, Yule's Q, and Cohen's Kappa) and non-pairwise metrics (Entropy and Kohavi-Wolpert). Sixteen base classifiers and five meta-learners were trained using repeated 10-fold cross-validation. The framework was evaluated using data from 4,778 hospitalized COVID-19 patients with 116 clinical and laboratory attributes, preprocessed using robust scaling and ROSE-based class balancing. RESULTS: The optimal configuration, which stacked Random Forest and XGBoost models using a Neural Network meta-learner, achieved 91.4% accuracy (95% CI: 89.8-92.8), AUC = 0.955, F1 = 0.801, and MCC = 0.746, outperforming the best individual model (AdaBoost, 90.2%). Training time (~450 s) and per-case inference time (<0.2 s) demonstrated computational feasibility. Feature-importance analysis and SHAP-based interpretation confirmed clinical relevance and interpretability. CONCLUSIONS: The hybrid feature-selection and diversity-guided stacking framework improves predictive accuracy and interpretability while maintaining computational efficiency. Although validated using COVID-19 mortality data, the approach is broadly applicable to biomedical, environmental, and engineering prediction tasks that require interpretable and scalable ensemble learning.
19 Apr 2026
Read appraisal →Archives of disease in childhood. Fetal and neonatal edition
Closed-loop automated oxygen control in preterm ventilated infants: a randomised controlled trial
OBJECTIVE: To compare the duration of mechanical ventilation between preterm infants receiving closed-loop automated oxygen control (CLAC) or manual oxygen control. DESIGN: Randomised controlled trial. SETTING: Tertiary neonatal unit in London, UK. PATIENTS: Infants (n=69) with a median (IQR) gestational age of 27.0 (25.6-29.0) weeks studied at a corrected postmenstrual age of 27.6 (25.9-29.1) weeks. INTERVENTIONS: Infants were randomised to CLAC or manual oxygen control within 48 hours of initiation of mechanical ventilation if less than 7 days of age until successful extubation. MAIN OUTCOME MEASURES: Duration of mechanical ventilation. RESULTS: The CLAC infants (n=34) compared with those who received manual control had a shorter duration of mechanical ventilation (median (range): 11 (1-57) vs 40 (3-134) days, p=0.027), a shorter duration of supplemental oxygen (median (range): 33 (0-100) vs 47 (3-335) days, p=0.031), a lower incidence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (55% vs 83.9%, p=0.015) and fewer required home oxygen (26.5% vs 51.4%, p=0.016). In the CLAC infants, the time spent in the target oxygen range (91%-95%) was increased (p<0.001) and the times spent in hypoxaemia (peripheral oxygen saturation level (SpO2)<85%) and hyperoxaemia (SpO2>95%) were reduced (p<0.001). CONCLUSIONS: Use of CLAC in preterm, ventilated infants was associated with improved achievement of oxygen saturation targets, shorter durations of mechanical ventilation and supplemental oxygen treatment and a lower incidence of BPD. These results need to be replicated in larger multicentre studies before any change in routine practice could be recommended. TRIAL REGISTRATION NUMBER: NCT05030337.
19 Apr 2026
Read appraisal →Nature communications
Donor-derived regulatory dendritic cell infusion and early immunosuppressive drug withdrawal in living-donor liver transplantation: a phase I/IIa trial
Operational tolerance (OT) following complete immunosuppression withdrawal (ISW) is rare ( ~ 13%) in eligible adult liver transplant recipients when initiated 1-2-years post-transplant. Regulatory dendritic cells (DCregs) promote transplant tolerance in pre-clinical models and attenuate immune effector cells in humans. Here, we completed a first-in-human phase I/IIa trial (2-year recruitment; 5 ± 0.5 years follow-up) to evaluate the feasibility, safety and preliminary efficacy of pre-emptive donor-derived DCreg (ddDCreg) infusion 7-days pre-transplant in 15 prospective living-donor liver recipients. Two patients were excluded from analysis for reasons unrelated to the study. ISW began one year post-transplant in candidates with a quiescent/permissive protocol biopsy. ddDCreg infusions were safe, reproducible, and well-tolerated. One-year post-transplant, 8/13 patients were eligible for ISW, 4 achieved complete ISW, 3 remained off all immunosuppression for >1 year. These 3 remained drug-free for 3.0 ± 0.17-years, reflecting a 37.5% OT rate in ISW-eligible recipients. Given the exploratory nature of this trial, additional studies to evaluate efficacy are needed. ClinicalTrials.gov registration number NCT03164265.
19 Apr 2026
Read appraisal →Medicine
Publication trends of dexmedetomidine and perioperative cognitive dysfunction: A bibliometric analysis from 1995 to 2024
INTRODUCTION: Dexmedetomidine (Dex) has shown potential in mitigating perioperative cognitive dysfunction (POCD). This study aimed to systematically evaluate the research hotspots and development trends in Dex and POCD using bibliometric analysis. METHODS: A systematic search was conducted on the Web of Science Core Collection database to identify publications related to Dex and POCD from 1995 to 2024. Bibliometric analysis was performed using VOSviewer (V 1.6.20), CiteSpace (V 6.3.R1), and R V4.3.3. RESULTS: A total of 585 articles on Dex and POCD between 1995 and 2024 were analyzed. These articles involved 1688 authors from 1857 institutions across 140 countries or regions, published in 240 journals, and citing 12,881 sources. The annual growth rate of publications in this field was 16.21%, with a peak of 91 articles in 2021. China led in the number of articles (n = 379), multiple country publications (MCP = 29), and total citations = 4989). The USA ranked second with 74 articles, 18 MCPs, and 2608 citations, followed by South Korea with 29 articles and 533 citations. Harvard University published the most articles (n = 51). Wang Dong-Xin was the most influential author, with an h-index of 7. Anesthesiology led the high-impact journals with an H-index of 11. The keyword analysis identified "neuroinflammation," "risk," "injury," and "efficacy" as the latest research themes. CONCLUSION: This bibliometric analysis provides a comprehensive overview of the research trends regarding Dex and POCD. Future research should continue to explore the mechanisms, efficacy, and safety of Dex in preventing POCD.
18 Apr 2026
Read appraisal →Sleep
Improving sailor's amount and efficiency of sleep in two-section watchkeeping schedules: A cluster randomized trial study
STUDY OBJECTIVES: The present study aimed at comparing sailors' amount and efficiency of sleep in two two-section watchkeeping schedules, i.e. the traditional 6/6 and the 7-5-5-7. Intention for the latter schedule was to align the major sleep episodes with biologically driven nocturnal sleep patterns. METHODS: Using a parallel crossover design with cluster randomized trials, forty-eight crew members from two vessels of the German Navy participated in a field trial with two 1-week underway periods varying the watchkeeping schedule in randomized order. Sleep minutes and sleep efficiency were assessed on the participant level using wrist-worn actigraphs and analyzed for sleep episodes occurring during the day (i.e. between 10:00 am and 10:00 pm) and during the night (i.e. between 10:00 pm and 10:00 am). RESULTS: Nighttime sleep duration was 14 min longer and with 10% higher sleep efficiency in the 7-5-5-7 schedule compared to the 6/6. In contrast, daytime sleep duration was 40 min longer in the 6/6 with no statistically significant differences in sleep efficiency between the two watchkeeping schedules. CONCLUSIONS: Our results suggest that the amount and efficiency of nighttime sleep can be enhanced with the 7-5-5-7. Hence, even in shift schedules with restricted periods for rest, recuperation can be improved by more closely aligning watchkeeping schedules to the innate human diurnal circadian cycles. Statement of Significance The size of ships and the associated limitations on the size of their crews make two-section watchkeeping schedules common in civil and military maritime settings. Such watchkeeping schedules-in which the 24-h day must be shared between two watches-limit time available for rest and recuperation. The present study shows that even in this context, slight modifications in two-section watchkeeping schedules lead to more and better nighttime sleep because the circadian fluctuations of sleep and performance are considered. Our research findings have high practical significance for all industries with shift workers and demonstrate how the negative effects of watchkeeping schedules can be reduced if they are adapted to better align with innate human circadian rhythms.
17 Apr 2026
Read appraisal →The New England journal of medicine
Selective Decontamination of the Digestive Tract during Ventilation in the ICU
BACKGROUND: Whether selective decontamination of the digestive tract (SDD) reduces mortality among patients undergoing mechanical ventilation and whether it adversely affects microbial ecology in the intensive care unit (ICU) remain unclear. In an earlier analysis of data from Australia, SDD did not result in a lower incidence of in-hospital death than standard care, but data from the full international trial are needed. METHODS: We randomly assigned ICUs in Australia and Canada to use SDD or to continue standard care for two 12-month periods in patients undergoing mechanical ventilation. Patients in the SDD group received specific oral and gastric antimicrobial interventions for the duration of ventilation and an intravenous antibiotic agent for the first 4 days after enrollment. All other patients in the ICU were included in an observational ecologic assessment. Previously reported data from Australia are now combined with data from Canada. The primary outcome was in-hospital death from any cause at 90 days. The secondary clinical outcomes, assessed at 90 days, were death in the ICU and the number of days alive and free of mechanical ventilation, ICU admission, and hospitalization. Microbiologic secondary outcomes included new positive cultures for bloodstream infections and antibiotic-resistant organisms. For the ecologic assessment, the microbiologic outcomes were tested for noninferiority (noninferiority margin, 2 percentage points). RESULTS: In this trial involving 20,000 patients in 26 ICUs, 9289 patients were enrolled in the randomized trial and 10,711 were included in the ecologic assessment. At 90 days, 1175 of 4215 patients (27.9%) in the SDD group and 1494 of 5065 (29.5%) in the standard-care group had died before hospital discharge (odds ratio, 0.94; 95% confidence interval [CI], 0.84 to 1.05; P = 0.27). New bloodstream infections occurred in 4.9% of the patients in the SDD group and in 6.8% of those in the standard-care group (adjusted mean difference, -1.30 percentage points; 95% CI, -2.55 to -0.05); antibiotic-resistant organisms were cultured in 16.8% and 26.8%, respectively (adjusted mean difference, -9.60 percentage points; 95% CI, -12.40 to -6.80). In the ecologic assessment, noninferiority of SDD was not confirmed for the development of new antibiotic-resistant organisms. Adverse events considered to be related to SDD or standard care were reported in 12 patients (0.3%) in the SDD group and in no patients in the standard-care group. Serious adverse events occurred in 47 patients (1.1%) and 59 patients (1.2%), respectively. CONCLUSIONS: Among critically ill patients undergoing mechanical ventilation, SDD did not result in a lower incidence of in-hospital death than standard care. (Funded by the National Health and Medical Research Council of Australia and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT02389036.).
16 Apr 2026
Read appraisal →The Cochrane database of systematic reviews
Insulin-like growth factor-1 for the prevention or treatment of retinopathy of prematurity
RATIONALE: Retinopathy of prematurity (ROP) is a disorder of the developing retina in which abnormal proliferation of retinal blood vessels may lead to severe visual compromise or retinal detachment in infants born preterm. Insulin-like growth factor-1 (IGF-1) promotes normal retinal vessel growth in utero; however, IGF-1 levels fall substantially following preterm birth. By returning IGF-1 to in utero levels, postnatal treatment with IGF-1 may interrupt ROP pathogenesis, preventing disease or reducing its severity. OBJECTIVES: To compare treatment with IGF-1 to standard care or placebo for the prevention of retinopathy of prematurity or treatment of early retinopathy of prematurity. SEARCH METHODS: We used CENTRAL, MEDLINE, Embase, Cochrane Database of Systematic Reviews, Issue 3, 2025, in the Cochrane Library, CINAHL Plus with Full Text (EBSCOhost), Epistemonikos, clinical trials registries (US National Library of Medicine Clinicaltrials.gov, World Health Organization's International Trials Registry Platform, and ISRCTN Registry), together with reference checking and citation searching to identify studies that are included in this review. The latest search date was 10 March 2025. ELIGIBILITY CRITERIA: We considered all randomized controlled trials (RCTs), cluster-RCTs, and quasi-RCTs comparing IGF-1 with standard care or placebo for the prevention of ROP or treatment of early ROP in preterm infants. We planned to exclude cross-over randomized trials. OUTCOMES: Our outcomes of interest were: • Development of Type 1 ROP, defined as ROP requiring treatment at any time during the birth hospitalization or outpatient follow-up • Development of ROP ≥ stage 3 at any time during the birth hospitalization or outpatient follow-up • Development of ROP of any severity at any time during the birth hospitalization or outpatient follow-up • Occurrence of one or more serious adverse events (SAEs) at any time during the birth hospitalization • Mortality during the birth hospitalization • Hypoglycemia during the birth hospitalization RISK OF BIAS: We used the original Cochrane Risk of Bias 1 tool (RoB 1) to assess possible bias in the included studies. SYNTHESIS METHODS: Dichotomous data were reported using risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CIs). Where possible, we synthesized results for each outcome using meta-analysis with fixed-effect models. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included two studies totaling 140 participants. Both included studies were parallel-group RCTs performed between 2011 and 2016 enrolling extremely preterm infants in well-resourced settings in Europe and North America. The two published primary study references describe a two-center RCT (n = 19) and a 20-center RCT (n = 121) comparing treatment starting on the first day of life with intravenous IGF-1 (as mecasermin rinfabate) to standard care for prevention of ROP in newborn infants at 23 weeks' to 27 weeks plus six days' gestational age with follow-up through 40 weeks' postmenstrual age. SYNTHESIS OF RESULTS: Type 1 ROP/ROP requiring treatment Evidence is very uncertain regarding the effect of treatment with IGF-1 as compared to standard care/placebo for preventing development of Type 1 ROP/ROP requiring treatment (RR 0.94, 95% CI 0.38 to 2.35; P = 0.90; I2 = 0%; 2 RCTs, 116 infants; very low-certainty evidence). ROP ≥ stage 3 Evidence is very uncertain regarding the effect of treatment with IGF-1 as compared to standard care/placebo for preventing development of severe ROP (RR 1.27, 95% CI 0.61 to 2.65; P = 0.52; I2 = 0%; 2 RCTs, 116 infants; very low-certainty evidence). ROP of any severity Evidence is very uncertain regarding the effect of treatment with IGF-1 as compared to standard care/placebo for preventing development of ROP of any severity (RR 1.30, 95% CI 0.94 to 1.80; P = 0.12; I2 = 0%; 2 RCTs, 116 infants; very low-certainty evidence). SAEs during the birth hospitalization Evidence is very uncertain regarding the safety of treatment with IGF-1 as compared to standard care/placebo as reflected by the occurrence of one or more SAEs during the birth hospitalization in preterm infants (RR 1.18, 95% CI 0.94 to 1.47; P = 0.15; I2 = 65%; 2 studies, 140 infants; very low-certainty evidence). Post-hoc sensitivity analysis including only the larger RCT demonstrated an increased risk of experiencing one or more SAEs with IGF-1 compared to controls (RR 1.28, 95% CI 1.01 to 1.62, P = 0.05; RD 0.17, 95% CI 0.01 to 0.33, P = 0.04; number needed to treat for an additional harmful outcome (NNTH) 5.9; I2 = not applicable; 1 RCT, 121 infants; very low-certainty evidence). All-cause mortality during the birth hospitalization Evidence is very uncertain regarding the effect of treatment with IGF-1 as compared to standard care/placebo on all-cause mortality during the birth hospitalization in preterm infants (RR 1.69, 95% CI 0.71 to 3.99; P = 0.23; I2 = not applicable; 1 RCT, 121 infants; very low-certainty evidence). Hypoglycemia during the birth hospitalization Evidence is very uncertain regarding the safety of treatment with IGF-1 as compared to standard care/placebo as reflected by the incidence of hypoglycemia in preterm infants during the birth hospitalization (RR 1.00, 95% CI 0.62 to 1.63; P = 0.99; I2 = 0%; 2 RCTs, 140 infants; very low-certainty evidence). We assessed all results to be of very low certainty due to small total enrollment and substantial risk of bias. Both included studies had a high risk of bias in two domains. In addition, both were funded by industry. AUTHORS' CONCLUSIONS: The available data are of very low certainty, and so we are not able to draw conclusions about the effects of treatment with IGF-1 in preterm infants for preventing or treating ROP, or about its effects on risk of serious adverse events, mortality, or hypoglycemia in this population. FUNDING: This Cochrane review had no dedicated funding. REGISTRATION: Protocol available via DOI: 10.1002/14651858.CD013216.
16 Apr 2026
Read appraisal →International journal of medical informatics
Clinician preferences for explainable AI in critical care: a comparative study of interpretable models and visualizations for intubation decision support
BACKGROUND: The complexity of many AI models hinders their clinical adoption because the clinicians using them do not regard them as transparent. This study addresses the lack of clinician-centered explainable AI (XAI) interfaces by designing and evaluating intuitive visual explanations for intubation prediction, testing the hypothesis that workflow-compatible designs enhance acceptance. OBJECTIVE: This study compares three, time-aware, visual explanations for XAI-based intubation prediction and evaluate their acceptance, comprehension, and perceived utility among clinicians. METHODS: We developed machine learning models to estimate the near-term risk of deterioration in the patient's condition which may lead to mechanical intubation using ICU time-series data. We generated global and local explanations using SHAP and designed three customized visual formats-a temporal force plot, a temporal bar chart, and a dual-encoded SHAP heatmap. Clinicians (n = 206) evaluated comprehension and usability using objective questions and a Likert-based survey. RESULTS: Based on 4608 critically ill patients with 10 medical variables over 7 hours of data for each patient, the Random Forest (RF) model achieved the highest area under the curve (AUC): 0.94. Furthermore, the local explanations were customized and evaluated by 206 clinicians through a survey conducted on the Prolific platform. A customized heatmap representation was selected as the visualization with the highest perceived clinical utility and alignment with clinical workflows. DISCUSSION: The reported findings support the need for explanation formats to be tailored to clinical reasoning and task context, supporting the concept of cognitive fit. The heatmap's close alignment with clinicians' mental models and its graphical integrity enhances interpretability and trust. This study demonstrates that explanation effectiveness depends on contextual relevance, rather than a universal standard, and that the presentation format itself significantly shapes clinicians' trust in XAI systems. CONCLUSION: This study advances clinical XAI by introducing a time-aware explanation framework for ICU intubation decisions. By integrating temporal trends with model reasoning, our visualizations closely align with clinicians' cognitive workflows. Rigorous clinician-centered evaluation identified the dual-encoded SHAP heatmap as the most useful and workflow-compatible visualization, highlighting the importance of explanation design alongside predictive accuracy for clinical adoption.
15 Apr 2026
Read appraisal →A&A practice
Hypotension Prediction Index-Guided Hemodynamic Management on Postoperative Organ Outcome: A Systematic Review and Meta-Analysis of Randomized Clinical Trials
Intraoperative hypotension (IOH) is a frequent occurrence during noncardiac surgery. Hypotensive episodes can compromise tissue perfusion, and cumulative exposure has been associated with adverse outcomes such as acute kidney injury (AKI), myocardial injury, and increased mortality. The Hypotension Prediction Index (HPI) is an artificial intelligence tool designed to predict hypotensive events before they occur, allowing clinicians to intervene proactively to prevent or mitigate hypotension. Although randomized trials and pooled analyses have shown its effectiveness in reducing both the incidence and duration of IOH, its impact on patient-centered outcomes remains unclear. From 1946 to August 8, 2025, we prospectively queried MEDLINE (PubMed), Embase, Cochrane Library, and Web of Science. We included randomized controlled trials in adult surgical patients with invasive arterial monitoring, comparing HPI-guided perioperative hemodynamic management to standard care. Primary outcome was postoperative AKI, and secondary outcomes were postoperative myocardial injury, pneumonia, arrhythmia, stroke, postoperative cognitive dysfunction, including delirium, surgical site infection, length of hospital stay, and mortality. Two authors independently evaluated the risk of bias according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using RevMan 5.4.1 software. Dichotomous data were presented as risk ratio, 95% confidence interval [CI]; continuous data were presented as mean difference, 95% CI. All results were pooled using random-effects models. Of 883 imported references, 14 studies (N = 2030) were included for final analysis. No significant difference in incidence of postoperative AKI was observed between HPI-guided management and standard care, RR = 0.87, 95% CI (0.71-1.07). Postoperative myocardial injury was significantly reduced in HPI-guided management group, RR = 0.61, 95% CI (0.39-0.96), although exclusion-based sensitivity analysis suggests that this finding may not be robust. No other significant differences were observed for hospital length of stay, arrhythmia, stroke, cognitive dysfunction (including delirium), surgical site infection, pneumonia, or mortality. Although HPI-guided management is associated with a reduction in postoperative myocardial injury, its significance does not withstand sensitivity analysis. All other postoperative complications, including AKI incidence, are not reduced in the intervention groups. This study has limitations inherent to the heterogeneity of included patient populations, surgical interventions performed, standard of care practices, and reporting of postoperative outcomes.
15 Apr 2026
Read appraisal →Medicine
Prognostic factors for mortality in age-stratified elderly sepsis patients: A retrospective cohort study based on the MIMIC-IV database
Sepsis represents a major cause of death among elderly patients; however, prognostic factors specific to different age strata within this population remain insufficiently characterized. This retrospective cohort study aimed to identify early predictors of mortality in elderly sepsis patients using the MIMIC-IV database. We included 13,461 sepsis patients aged ≥60 years, stratified into younger-old (60-74 years; n = 7618) and older-old (75-90 years; n = 5843) groups. Propensity score matching was applied to balance baseline characteristics, yielding 4657 matched patients per group. Multivariable logistic regression, receiver operating characteristic analysis, and Kaplan-Meier survival curves were employed to assess clinical and biochemical markers for 28-day mortality and to identify age-specific prognostic indicators. These findings underscore the importance of age-stratified prognostic models to guide targeted clinical interventions and potentially improve outcomes in elderly patients with sepsis. Lactate dehydrogenase (LDH) and the PaO2/FiO2 ratio emerged as key mortality predictors in the younger-old group, whereas urea nitrogen and hypoalbuminemia were predominant in the older-old group. Urine output served as a common predictor across both strata, with oliguria associated with a 2.5-fold increase in mortality risk among older patients. While a combination of predictors enhanced prognostic accuracy in younger-old patients, this was not observed in the older-old group, suggesting a greater influence of frailty and comorbidities in advanced age.
12 Apr 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
A machine-learning-based tool for stroke risk prediction in blunt cerebrovascular injury: development and preliminary evaluation
PURPOSE: Stroke risk correlates with the Biffl grading system in blunt cerebrovascular injury (BCVI). Although anti-thrombotic therapy is the mainstay of stroke prevention, no point-of-care clinical decision-support tool exists to guide timing for therapy. We sought to develop an interactive online calculator that incorporates patient-specific demographic and injury characteristics to estimate stroke risk and risk reduction with anti-thrombotic (AT) administration. METHODS: Data from BCVI patients (n = 1,197) at a Level I Trauma Center were retrospectively collected. Six machine learning methods were employed to predict stroke risk with and without AT therapy. Class imbalance was addressed using downsampling and/or class weighting. Model performance was assessed using 10-fold cross-validation. The model was implemented as an R-based Shiny online application. RESULTS: Stroke rate among the population was 4%, and the strongest predictors for stroke were the greatest Biffl grade of carotid (aOR [95%CI] = 2.02 [1.62-2.53]) and vertebral injuries (1.44 [1.18-1.77]). The least absolute shrinkage and selection operator (LASSO) model outperformed all others, achieving 66% [33%-100%] sensitivity and 74% [62%-82%] specificity for stroke prediction, with an area under the receiver operating characteristic curve of 0.79 [0.57-0.95]. This model was integrated into an interactive online tool ( https://grady-bcvi-calc.shinyapps.io/calculator/ ), where patient demographic and injury characteristics can be used to compute baseline stroke risk and estimate stroke risk with AT. CONCLUSION: We developed and evaluated a preliminary predictive model for personalized stroke risk assessment in patients with BCVI using key risk factors. The integration of patient-specific risk-benefit assessments into clinical decision-making could optimize and reduce variability in AT therapy. External validation is warranted to prepare this tool for broad clinical applicability.
11 Apr 2026
Read appraisal →Annals of medicine
Comparison of VCV and PCV-VG modes on diaphragmatic function in diabetic patients undergoing laparoscopic colorectal surgery: a prospective randomized controlled study
BACKGROUND: Diabetic patients are prone to induce diaphragmatic weakness, which can lead to postoperative pulmonary complications (PPCs). The optimal mechanical ventilation mode may potentially improve postoperative diaphragmatic function. This study evaluates the effects of two ventilation modes under driving pressure-guided ventilation strategy on diaphragmatic function, as assessed by diaphragm thickening fraction (DTF) and diaphragm excursion (DE), in diabetic patients following laparoscopic colorectal surgery. METHODS: Eighty patients diagnosed with Type II diabetes scheduled for elective laparoscopic colorectal surgery, were randomly allocated to either the pressure-controlled volume-guaranteed ventilation (PCV-VG) group (Group P) or the volume-controlled ventilation (VCV) group (Group V) during surgery. The primary outcome was diaphragmatic function assessed during both tidal breathing and maximal inspiratory effort after surgery. Secondary outcomes included intraoperative mechanical power, PPCs, and other complications. RESULTS: A total of eighty patients were included in the final analysis. The averaged area under the curve (AUC) for mechanical power during ventilation was significantly lower in Group P than in Group V (p = 0.002). PCV-VG significantly improved both DE and DTF within the first two days post-surgery (AUCDEtidal: p = 0.088, AUCDTFtidal: p = 0.004, AUCDEmax: p = 0.029, AUCDTFmax: p = 0.017). Postoperative diaphragmatic weakness was less frequent in Group P than in Group V (p = 0.019). However, there was no difference in the incidence of PPCs between the two groups (p = 0.155). CONCLUSION: PCV-VG mode can reduce intraoperative mechanical power, better preserve postoperative diaphragmatic function. However, these improvements did not translate into clinical benefits, as evidenced by the lack of reduction in the incidence of PPCs.
10 Apr 2026
Read appraisal →PloS one
A decade of triage with the Manchester Triage System-The MTS big data study
BACKGROUND: Over the past 25 years, numerous studies have evaluated triage system performance, but longitudinal data are limited. This study is the first to assess the Manchester Triage System (MTS) over a decade to determine the accuracy of initial patient assessments and system stability under external influences such as staff turnover, health policy changes, demographic shifts, and the COVID-19 pandemic. METHODS: We conducted a large-scale, monocentric, retrospective observational study at a tertiary care hospital. RESULTS: Between 2014 and 2023 a total of 355,135 emergency patients were included. Average age increased from 48.1 to 52.1 years. The distribution of the five MTS urgency levels remained stable. Prediction of hospital admission (AUC 0.719-0.756) and ICU admission (AUC 0.831-0.862) was consistent throughout the period. Twelve-hour survival probabilities were above 0.99 for "blue" to "orange" patients and above 0.89 for "red" patients. Short-term mortality prediction (AUC) ranged from 0.845 to 0.894. Thirty-day survival remained >0.8 for "blue" to "orange" stages, while the "red" stage declined from 0.63 (2014) to 0.44 (2023). The AUC for 30-day mortality increased from 0.672 to 0.750 over the decade. CONCLUSION: Construct validity assessment demonstrates that the MTS reliably assigns appropriate urgency levels to incoming emergency patients. Longitudinal evaluation shows that its accuracy remained stable over ten years despite high staff turnover, health policy and demographic changes, and the COVID-19 pandemic. These findings confirm the robustness and reliability of the MTS in a high-volume tertiary care setting and support its continued use for emergency patient prioritization.
10 Apr 2026
Read appraisal →Physiological measurement
Continuous blood pressure monitoring via hemodynamic parameter and pulse transit time derived from capacitive sensing pads
Objective.Continuous blood pressure (BP) monitoring is crucial for detecting nocturnal hypertension and acute hemodynamic changes. Conventional cuff-based methods disrupt sleep and miss transient BP fluctuations from sleep-related events or instability. Cuffless methods, such as pulse transit time (PTT), offer potential but often struggle to reliably track acute BP fluctuations due to complex and nonlinear hemodynamics.Approach.We developed a capacitive sensing pad system incorporating PTT with additional hemodynamic features for unobtrusive, continuous BP monitoring in supine subjects. The pad contains ultra-sensitive single-electrode capacitive (SEC) sensors made from carbon nanotube composites. In passive contact, SEC sensor on the back of the chest captures intrathoracic blood volume changes through deep tissue permittivity and ballistocardiography, while another under the leg detects arterial pulse-induced tissue vibrations. PTT is derived from the temporal delay between chest and leg signals. A neural network model incorporates PTT and intrathoracic blood volume features to improve BP estimation.Main results.In human trials (N= 30) with arm-cuff reference, the system showed strong correlation (r⩾ 0.94), with a mean error (ME) ⩽ 0.1 mmHg and standard deviation (SD) ⩽ 5.6 mmHg. In a subset (N= 8) with continuous finger-cuff reference, it maintained strong correlation (r⩾ 0.89), with a ME ⩽ 0.2 mmHg and SD ⩽ 7.8 mmHg.Significance.These results suggest the possibility of bed-based unobtrusive and continuous BP monitoring in the supine position.
9 Apr 2026
Read appraisal →Microbiology spectrum
Evaluation of contezolid's cerebrospinal fluid concentration and safety in tuberculous meningitis patients
Tuberculous meningitis (TBM) is the most severe form of tuberculosis (TB) with high mortality. This study evaluated the cerebrospinal fluid (CSF) concentration and safety of the novel oxazolidinone contezolid compared to linezolid in TBM patients. In this randomized prospective study, 10 TBM patients received either a linezolid-containing (n = 5) or contezolid-containing (n = 5) anti-TB regimen. CSF and blood concentrations were measured at 2 and 6 h post-dose. Peak (2 h) and trough (6 h) concentrations, area under the concentration-time curve (AUC), and safety were assessed. Contezolid CSF concentrations exceeded the Mycobacterium tuberculosis (Mtb) MIC (0.5 μg/mL) at 2 h (median: 1.0806 μg/mL, range: 0.9295-1.3165 μg/mL) but declined by 6 h (median: 0.7920 μg/mL, range: 0.1867-1.0194 μg/mL). Linezolid CSF concentrations were significantly higher than contezolid at both 2 h (median: 3.251 μg/mL, range: 1.9545-4.9636 μg/mL; P = 0.008) and 6 h (median: 1.623 μg/mL, range: 0.941-1.765 μg/mL; P = 0.016), remaining above MIC in all samples at 6 h. The mean CSF AUC for contezolid (4.637 μg·h/mL, 95% CI: 3.599-5.675) was significantly lower than that for linezolid (12.537 μg·h/mL, 95% CI: 7.8797-17.277; P = 0.008). Blood concentrations were higher than CSF for both drugs at all time points. No serious drug-related adverse events occurred. Contezolid effectively penetrates the blood-CSF barrier in TBM patients, achieving CSF concentrations above the MIC for Mtb. Although its CSF exposure was significantly lower than linezolid, its demonstrated penetration and safety profile suggest contezolid warrants further investigation as a potential treatment option for drug-resistant TBM.IMPORTANCETuberculous meningitis (TBM) is the deadliest form of tuberculosis, especially difficult-to-treat drug-resistant TBM. Finding new, effective, and safe medicines is critical. This study provides evidence in TBM patients that a newer antibiotic, contezolid, successfully reaches the infection site in cerebrospinal fluid (CSF) at levels expected to kill Mycobacterium tuberculosis. While linezolid achieved higher levels in CSF, contezolid still reached concentrations predicted to be effective and caused no serious side effects in our study. This is important because contezolid might offer a safer alternative to linezolid, which can have significant long-term toxicity. These promising results suggest contezolid could become a valuable new weapon against refractory drug-resistant TBM, potentially saving lives where current options are limited or too toxic.
9 Apr 2026
Read appraisal →Biomedical physics & engineering express
Bluetooth low energy thermohygrometric sensor for continuous respiratory rate monitoring: 48 h breathing simulator and human proof-of-concept
Continuous respiratory rate monitoring is essential for early detection of clinical deterioration, but conventional methods like capnography are often impractical outside high-acuity settings. We developed a low-cost, Bluetooth Low Energy (BLE) respiratory rate monitor incorporating a MEMS temperature-humidity sensor (AHT21) and Nordic nRF52840 microcontroller, designed to attach externally to a standard oxygen mask. The device detects breaths using rapid, cyclic changes in exhaled temperature and humidity via a slope-based time-domain algorithm. Bench validation over 48 h using a breathing simulator (5-60 breaths min-1, tidal volume 300 ml, 34 °C, 95%-100% RH) demonstrated 96.4% overall breath detection accuracy and strong correlation with programmed rates (r = 0.996, P < 0.0001). Sensor saturation occurred at high respiratory rates (60 breaths min-1), and high ambient humidity levels (90% RH) both of which reduced measurement accuracy. Human testing in three healthy adults showed strong agreement with capnography (mean bias 0.44 breaths min-1; 95% limits of agreement -1.86 to 2.75), with minor under-detection at the highest rate (50 breaths min-1). The device operated reliably across oxygen flow rates of 4-15 l min-1, with reduced performance at 0-2 l min-1due to saturation of the sensor. These results demonstrate that BLE-enabled MEMS thermohygrometric sensors can accurately monitor respiratory rate under controlled conditions while highlighting operational limits due to sensor saturation. This study extends prior work on humidity-based respiratory monitoring and illustrates the potential for low-cost, portable respiratory rate devices suitable for low-acuity or resource-limited clinical settings.
9 Apr 2026
Read appraisal →Gut
High versus gradually increasing energy nutrition in the early phase of acute pancreatitis (GOULASH): a multicentre double-blind randomised clinical trial
BACKGROUND: Acute pancreatitis (AP) is among the most common gastrointestinal diseases requiring hospitalisation, often with severe outcomes and no disease-specific therapy. Nutritional support has been proven to improve outcome, but little is known regarding optimal timing and composition. OBJECTIVE: This clinical trial aimed to compare high (30 kcal/kg/day, high energy (HE)) versus gradually increasing energy (0 increased to 30 kcal/kg/day over 4 days, low energy (LE)) strategies for enteral nutritional support in AP. DESIGN: This was a multicentric, double-blind, randomised clinical trial, enrolling patients with AP regardless of predicted severity (January 2017 to April 2023). The primary outcome was a combination of mortality and severe acute pancreatitis (Revised Atlanta Criteria); secondary outcomes included severity, rate of infection, organ failure and pain relapse. Interim analysis was planned after 50% enrolment. The Benjamini-Hochberg false discovery rate (FDR) method was used to correct p value for multiple testing. RESULTS: The trial was stopped early after enrolling 636 patients. Interim analysis showed that the primary outcome showed no difference between groups in the modified intention-to-treat (mITT) population (HE: 28/312, 9.0% vs LE: 18/307, 5.7%, p(uncorrected/corrected)=0.19/0.42). Secondary outcomes showed no difference in the mITT analysis. Without correction for multiplicity testing, results favoured a low gradual energy strategy in terms of organ failure (HE: 52/312, 16.7% vs LE: 28/307, 9.1%, p(uncorrected)=0.007) and pain relapse (80/312, 27.1% vs 54/307, 19.0% p(uncorrected)=0.03) but showed no differences between groups after correction for multiple testing (p=0.13 and p=0.23, respectively). It was determined that the superiority of the intervention would not be shown even with an increased sample size, and thus the trial was terminated based on a post hoc decision on ethics and futility. CONCLUSION: Based on this early terminated trial, a high-energy strategy for early nutrition in pancreatitis does not decrease mortality/severity, but potentially increases organ failure and pain relapse rate. TRIAL REGISTRATION NUMBER: ISRCTN63827758.
8 Apr 2026
Read appraisal →JAMA
Tenecteplase for Acute Non-Large Vessel Occlusion 4.5 to 24 Hours After Ischemic Stroke: The OPTION Randomized Clinical Trial
IMPORTANCE: The efficacy and safety of intravenous tenecteplase in non-large vessel occlusion acute ischemic stroke beyond 4.5 hours after symptom onset remain uncertain. OBJECTIVE: To assess the efficacy and safety of intravenous tenecteplase administered 4.5 to 24 hours after stroke onset in patients with non-large vessel occlusion and salvageable brain tissue. DESIGN, SETTING, AND PARTICIPANTS: This randomized, open-label, blinded end-point clinical trial was conducted at 48 centers in China. A total of 566 patients with non-large vessel occlusion stroke and evidence of potentially salvageable tissue determined on perfusion imaging presenting within 4.5 to 24 hours of the time last seen well were recruited between June 2, 2023, and August 4, 2025 (final follow-up, October 28, 2025). INTERVENTIONS: Patients were randomly assigned 1:1 using a minimization algorithm to receive intravenous tenecteplase (0.25 mg/kg; maximum dose, 25 mg; n = 282) or standard medical treatment (n = 284). MAIN OUTCOMES AND MEASURES: The primary efficacy outcome was an excellent functional outcome, defined as a score of 0 or 1 on the modified Rankin Scale at 90 days. Safety outcomes included symptomatic intracranial hemorrhage within 36 hours and mortality within 90 days. RESULTS: Among the 570 patients randomized, 566 were included in the primary analysis (median age, 68 [IQR, 59-75] years; 196 female [34.6%]). An excellent functional outcome was observed in 123 of 282 patients (43.6%) in the tenecteplase group and 97 of 284 (34.2%) in the control group (risk ratio, 1.28 [95% CI, 1.04-1.57]; P = .02). The incidence of symptomatic intracranial hemorrhage at 2.8% was higher with tenecteplase than with standard medical treatment at 0% (risk difference, 2.85% [95% CI, 1.16%-5.54%]; P = .004), and the mortality at 90 days was 5.0% and 3.2%, respectively (risk ratio, 1.57 [95% CI, 0.69-3.57]; P = .28). CONCLUSIONS AND RELEVANCE: Among patients with non-large vessel occlusion acute ischemic stroke and salvageable brain tissue, intravenous tenecteplase administered 4.5 to 24 hours after onset resulted in a greater likelihood of an excellent functional outcome at 90 days than standard care but had an increased risk of symptomatic intracranial hemorrhage. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05752916.
8 Apr 2026
Read appraisal →The European respiratory journal
Impact of positive airway pressure therapy on pulmonary arterial pressures in obstructive sleep apnoea or obesity hypoventilation syndrome: a systematic review and meta-analysis
BACKGROUND: There is limited and conflicting evidence on the impact of obstructive sleep apnoea (OSA) and its treatment with positive airway pressure (PAP) therapy on pulmonary hypertension (PH). Our research question was: does treatment of OSA and obesity hypoventilation syndrome (OHS) with PAP therapy improve pulmonary arterial pressures? METHODS: A systematic review and random effects meta-analysis was performed (PROSPERO: CRD42024595312). PubMed, Embase, Scopus, Web of Science, EBSCO, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov were searched using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies reporting pulmonary arterial pressure in patients with OSA and OHS pre- and post-PAP therapy were included. The primary outcome was post-PAP therapy change in pulmonary arterial pressures, with separate analyses on pulmonary arterial systolic pressure and mean pulmonary arterial pressure. Sensitivity analysis was performed to assess the impact of PAP therapy in patients with only OSA or OHS. RESULTS: 23 studies (20 observational and three randomised controlled trials) with 733 patients were included (19 with OSA (n=518) and four with OHS and concomitant OSA (n=215)). Most patients had severe OSA. PAP therapy was associated with a mean reduction in pulmonary arterial pressure of 5.96 (95% CI 3.20-8.73) mmHg; p<0.0001. In patients with baseline PH (n=233), the reduction was 11.41 (95% CI 8.66-14.15) mmHg; p<0.00001. The beneficial effect of PAP therapy was similar in OSA and OHS. There was no sex difference in the impact of PAP therapy. Heterogeneity was high across studies (I2>85%), reflecting differences in study design, patient populations and methodologies. CONCLUSIONS: PAP therapy reduces pulmonary arterial pressures in patients with mostly severe OSA or OHS, with a more pronounced effect in those with baseline PH. As such, our findings may not apply to patients with milder degrees of OSA. While reductions in pulmonary arterial pressures were observed in all groups, the low certainty necessitates cautious application of these findings in clinical practice.
5 Apr 2026
Read appraisal →AJNR. American journal of neuroradiology
Delphi Consensus on Early Neurologic Improvement after Mechanical Thrombectomy
BACKGROUND AND PURPOSE: Early neurologic improvement (ENI) following mechanical thrombectomy (MT) has been a topic of substantial interest. The literature has more than 40 ENI definitions, yet no consensus has been reached. In this Delphi study, we sought to investigate experts' perspectives on the available ENI definitions and determine whether a consensus can be achieved. MATERIALS AND METHODS: The Delphi approach assessed experts' perspectives on available ENI definitions. Following a systematic literature review, the first survey round was prepared and sent to 20 experts using a Web-based anonymous survey platform (qualtrics.com). The first round of questions was publicly shared on the letsgetproof.com platform to gather perspectives of neurointerventionalists worldwide on ENI definitions. Expert and volunteer answers formed the basis of subsequent rounds, in which closed-ended questions were sent only to experts. Consensus was defined as an agreement of ≥70% for binary closed-ended questions and ≥50% for closed-ended questions with >2 response options. RESULTS: Experts completed 3 survey rounds. They recognized that the heterogeneity in ENI definitions is the most critical factor limiting the use of ENI in clinical practice and stroke research. All experts acknowledged that stroke physicians need a standardized universal ENI definition. Consensus was reached on the notion that a unified ENI definition should focus on predicting functional independence at 3 months. They agreed that NIHSS improvement of ≥8 points at 24 hours could serve as the unified ENI definition. They acknowledged that incorporating prestroke comorbidities, occlusion location, baseline NIHSS scores, and procedure-related parameters would complicate the ideal ENI definition and limit its use in clinical settings. The experts could not reach a consensus on the potential utility of ENI as a primary end point in MT trials. CONCLUSIONS: In our Delphi analysis, experts agreed on an ENI definition. They did not endorse using different ENI criteria for patients with comorbidities, posterior circulation occlusions, or high baseline NIHSS scores. Further prospective studies are needed to validate or refine ENI definitions and to address the paucity of data on the prognostic utility of ENI in specific clinical scenarios.
5 Apr 2026
Read appraisal →Scientific reports
Potential of large language models for rapid clinical information support: evidence from acute kidney injury knowledge testing.
Large language models (LLMs) are increasingly applied in clinical contexts; however, to our knowledge, their performance in acute kidney injury (AKI) has not been directly compared with physician performance on standardized clinical knowledge assessments. We conducted a cross-sectional study to evaluate the performance of 13 publicly available LLMs and 123 volunteer participants at the 131st Annual Congress of the German Society of Internal Medicine in Wiesbaden, Germany. Both groups completed an identical AKI knowledge assessment consisting of two case vignettes and 15 single-best-answer multiple-choice questions. LLMs achieved a mean score of 13.5 out of 15 (90%), with several models reaching a perfect score, while human participants averaged 7.3 out of 15 (48.7%). Only 16.3% of participants scored 11 points or higher. As an illustrative example, ChatGPT-4o completed the test in approximately 0.5 minutes, whereas humans required a mean of 7.3 minutes. These findings demonstrate that LLMs substantially outperformed a heterogeneous group of medical professionals in AKI knowledge assessments and did so with markedly greater efficiency. While this highlights the potential of LLMs as rapid, cost-effective tools for clinical knowledge support, their role in real-world patient care remains undetermined, and human clinical judgment remains essential to ensure safe, context-sensitive, and patient-centered care.
5 Apr 2026
Read appraisal →BMJ paediatrics open
Oxygen therapy for children with an oxygen saturation of 90-93% in Malawi: the NoGoLO2 pilot randomised controlled trial
OBJECTIVE: Oxygen is a cornerstone treatment for pneumonia with hypoxaemia. WHO guidelines recommend oxygen therapy for children with a peripheral arterial haemoglobin oxygen saturation (SpO2) <90%. Children in low- and middle-income countries with an SpO2 of 90-93% are at increased risk of mortality and may benefit from oxygen therapy. We aimed to determine the feasibility of a randomised controlled trial comparing standard of care (no oxygen), low-flow nasal cannula (LFNC) and high-flow nasal cannula (HFNC) among children with pneumonia and an SpO2 of 90-93%. DESIGN: Pilot, open-label, three-armed randomised control trial (NCT06176664). SETTING: Salima District Hospital, Malawi. PATIENTS: Children 1-59 months old with WHO-defined pneumonia and an SpO2 of 90-93%. INTERVENTIONS: Standard care (no oxygen), LFNC or HFNC. MAIN OUTCOME MEASURES: The primary outcome was feasibility defined as an average of ≤2 protocol deviations per participant. Secondary outcomes included consent refusal, participant attrition and treatment failure within 14 days. Treatment failure was defined as an SpO2 <90% for standard care participants or <94% in the LFNC and HFNC arms despite maximum therapy as described, any new severe respiratory distress (grunting, very severe chest indrawing) or any new WHO-defined emergency sign. RESULTS: Of the 29 eligible patients, 21 (72%) were enrolled and randomised. There was an average of 0.8 (16/21) deviations per participant. Seven (43.8%) protocol violations were related to study intervention protocols and nine (56.3%) to medication availability and routine care. No participants withdrew from the study. Three of 21 participants (14.3%) had treatment failure. All participants were successfully followed to obtain the 14-day outcome. CONCLUSIONS: A three-armed, open-label randomised control trial is feasible to compare standard of care, LFNC and HFNC oxygen for children with pneumonia and an SpO2 of 90-93% in Malawi. TRIAL REGISTRATION NUMBER: NCT06176664.
4 Apr 2026
Read appraisal →Journal of neurology
Sonographic optic nerve sheath diameter measurement for detecting intracranial hypertension in a suspected population: a systematic review and meta-analysis of diagnostic thresholds and influencing factors
OBJECTIVES: In this study, we aimed to assess the clinical efficacy of sonographic optic nerve sheath diameter (ONSD) measurements for detecting intracranial hypertension (ICH). Our objectives included evaluating its diagnostic precision compared with invasive intracranial pressure (ICP) monitoring; exploring potential sources of heterogeneity, such as measurement technique (multi vs. single-planar), population demographics (Asian vs. non-Asian), and major etiologies; and determining validated thresholds for prompt bedside ICP assessment in acute neurological crises. DATA SOURCES: We comprehensively searched eight databases, including four in English (PubMed, Web of Science, MEDLINE®, and Embase) and four in Chinese (China National Knowledge Infrastructure [CNKI], Wanfang, VIP, and SinoMed). The search covered literature published from the inception of the databases up to May 31, 2025. STUDY SELECTION: This review includes prospective, retrospective, and case-control studies that assess the efficacy of sonographic ONSD measurement for detecting ICH, defined as an ICP exceeding 20 mm Hg, 20 cmH2O, 25 cmH2O with invasive ICP measurement as the gold standard. DATA EXTRACTION: X.T. and Q.T. independently screened the studies and assessed the risk of bias using the QUADAS-2 tool. STATISTICAL ANALYSIS: Diagnostic accuracy was pooled using a bivariate random-effects model to generate summary receiver operating characteristic (SROC) curves. Subgroup analyses of the measurement technique, study population, and etiology were conducted. Publication bias was assessed using Deeks' test. DATA SYNTHESIS: The decision tree analysis revealed that an ONSD ≥ 5.1 mm is the critical diagnostic threshold for detecting intracranial hypertension. The regression tree model indicated a range of CDEI values from 0.64 to 0.95, with a root node value of 0.82 (95% CI: 0.79-0.85). The incorporation of a multiplanar assessment significantly enhanced the prediction of favorable outcomes (CDEI > 0.85; p < 0.001). Moreover, compared with a 20 mmHg threshold, a 25 cmH₂O threshold resulted in greater specificity (88.4% vs. 82.9%) and a higher positive likelihood ratio (LR+ 6.5 vs. 5.0). The utilization of multiplane techniques and experienced operators notably improved diagnostic accuracy, leading to a 50% reduction in missed diagnoses (LR- 0.1). Nontraumatic brain injury cases exhibited superior sensitivity (91.9% vs. 85.2%) and a 107% higher diagnostic odds ratio (63.3 vs. 30.5) than traumatic brain injury cases did. CONCLUSIONS: Findings from this study suggest that an ONSD threshold ≥ 5.1 mm is a promising diagnostic marker for elevated ICP (> 20 cmH₂O/mmHg or acute etiology), although external validation is needed. A multiplane evaluation improves its predictive accuracy for favorable outcomes. The developed decision model supports the use of sonographic ONSD measurement as a supplementary screening tool in emergency and critical care, particularly when invasive monitoring is unavailable. Additionally, an ONSD of approximately 6.0 mm is a potential prognostic indicator for unfavorable outcomes, highlighting a key area for future research. These findings can only be applied after their validation through multicenter studies and the establishment of standardized measurement protocols.
4 Apr 2026
Read appraisal →The European respiratory journal
A European multicentre, randomised controlled trial of pirfenidone in bronchiolitis obliterans syndrome after bilateral lung transplantation
BACKGROUND: Chronic lung allograft dysfunction (CLAD) is a major obstacle to improving outcomes after lung transplantation. Bronchiolitis obliterans syndrome (BOS), characterised by progressive decline in forced expiratory volume in 1 s (FEV1) due to fibrotic scarring of the small airways, accounts for most CLAD cases. Pirfenidone, an antifibrotic agent used for idiopathic pulmonary fibrosis, was assessed for treating progressive BOS. METHODS: An investigator-initiated, international, multicentre, randomised, double-blind, placebo-controlled phase II trial was conducted in nine European lung transplant centres. Adults with bilateral lung transplants and progressive BOS were randomised (1:1) to receive pirfenidone 2403 mg·day-1 or placebo with standard care for 26 weeks. The primary end-point was change in FEV1 from baseline to week 26, with imputation for missing values. FINDINGS: From 1 May 2015 to 1 December 2019, 477 patients were screened, and 90 were randomised to pirfenidone (n=48) or placebo (n=42). Both groups showed continued decline in FEV1 from baseline to week 26, with no significant difference in intention to treat (ITT), ITT with imputation, or per-protocol analyses. Secondary end-points (graft loss, death, re-transplantation) were similar between groups. Treatment-related serious adverse events were distributed equally. INTERPRETATION: Pirfenidone did not show superiority over placebo and standard care in this exploratory trial. It cannot be recommended for treating BOS. Further research is needed to explore other treatments for CLAD to improve long-term outcomes after lung transplantation.
4 Apr 2026
Read appraisal →Yonsei medical journal
Predicting Post-Induction Hypotension in Diverse Surgical Populations: A Multiclass Classification Universal Model Using Machine Learning Techniques
PURPOSE: Our study aims to develop a machine learning model that not only predicts the occurrence of post-induction hypotension (PIH) but also assesses its severity, addressing a broader patient population than previous studies which mostly focused on a single population. MATERIALS AND METHODS: In our study, we extracted data from 71473 patients aged 18 years and older who underwent general anesthesia for non-cardiac surgery at a tertiary care hospital, using the electronic medical record system for modeling. We used patient demographics, baseline and pre-induction blood pressure, preoperative laboratory tests, surgical details, and anesthetics data, focusing on predicting PIH. The severity of hypotension was assessed by integrating and calculating the integral value of hypotensive periods. We employed several machine learning techniques and evaluated their performance using accuracy, precision, F1-scores, and macro-averaged area under the curve. Additionally, SHapley Additive exPlanation values were used to determine the key factors influencing the predictions. RESULTS: A multiclass classification model, which assesses hypotension severity through the area of hypotension, surpassed the binary model with an F1-score of 0.664. Among various machine learning techniques, the eXtreme Gradient Boosting (XGBoost) model exhibited superior prediction performance, achieving an accuracy of 0.755 and an F1-score of 0.664. Models using preoperative blood pressure and demographic data outperformed those using other datasets. CONCLUSION: We found that using the XGBoost ensemble machine learning technique aids in predicting PIH before surgery, and introducing a multiclass classification model that indicates the severity of hypotension to clinicians leads to an overall enhancement in prediction performance, thereby increasing its clinical utility for real-world applications.
4 Apr 2026
Read appraisal →Current opinion in anaesthesiology
Artificial intelligence-driven predictive analytics for postoperative management and recovery in trauma patients
PURPOSE OF REVIEW: Post-traumatic care is evolving from a reactive, protocol-driven paradigm to a predictive, personalized approach. This review examines how artificial intelligence and machine learning are redefining postoperative management by predicting complications before they manifest. RECENT FINDINGS: Recent literature (2023-2025) highlights three major advances: (a) the validation of gradient boosting algorithms (e.g. Extreme Gradient Boosting) that significantly outperform traditional scoring systems for predicting trauma-induced coagulopathy; (b) the development of interpretable, phenotype-specific models for venous thromboembolism risk stratification, particularly in traumatic brain injury; and (c) the emergence of real-time sepsis prediction tools that account for the sterile inflammation inherent to trauma. However, a recurring limitation in current research is the reliance on retrospective datasets and single-center validations, underscoring the critical need for rigorous external validation across diverse patient populations before widespread clinical adoption. SUMMARY: Artificial intelligence is not merely a monitoring tool but a driver of precision medicine in trauma. By leveraging diverse modalities, from computer vision in radiology to natural language processing in electronic health records, clinicians can now anticipate adverse events. To bridge the gap between algorithm and bedside, future efforts must focus on overcoming significant implementation barriers, such as data interoperability, and ensuring model generalizability.
4 Apr 2026
Read appraisal →Critical care clinics
Innovation, Technology, and Telemedicine in Critical Care
Critical care medicine is undergoing a major transformation driven by rapid technological innovation, digital integration, and telemedicine. This article examines how modern intensive care units (ICUs) are evolving into data-rich, precision environments equipped with advanced monitoring, organ support, and predictive analytics. Innovations such as artificial intelligence-enhanced decision support, portable ultrasound, and tele-ICU platforms are expanding diagnostic accuracy, remote access, and timely interventions. By tracing historical milestones to emerging technologies like smart ICUs and wearable biosensors, this article highlights the shift toward anticipatory, personalized care. It underscores the importance of evidence-based adoption to ensure these tools improve outcomes.
4 Apr 2026
Read appraisal →Physiological measurement
StructEIT: realistic 3D EIT model generation from CT scans for deep learning applications
Objective.Artificial intelligence has significantly improved image reconstruction quality across various medical imaging modalities. However, its application in electrical impedance tomography (EIT) reconstruction remains limited, mainly due to the absence of comprehensivein vivodatasets that incorporate realistic anatomical geometries and conductivity distributions. This limitation constrains the development of supervised and data-driven reconstruction methods.Approach.To address this bottleneck, we developed StructEIT, an integrated EIT modeling framework for generating anatomically and biophysically realistic EIT simulation models. The framework incorporates three key components: (1) a structure extraction module, which automatically processes human CT scans to extract body contours and organ boundaries, thereby providing high-fidelity spatial geometry for three-dimensional finite element modeling; (2) a surface electrode attachment module, which enables flexible and accurate placement of electrodes on irregular body surfaces, supporting diverse configurations and ensuring precise definition of the electrode-tissue interface; and (3) a tissue property assignment module, which establishes frequency-dependent conductivity models for multiple organs, enabling physiologically realistic conductivity values across tissues.Main results and Significance.By bridging the gap between CT imaging and EIT, StructEIT facilitates flexible, realistic, and scalable generation of high-resolution EIT datasets. Using this framework, we constructed Chest-EIT, a thoracic EIT simulation dataset comprising over 1400 publicly available CT cases, with multiple electrode configurations provided for each case.
4 Apr 2026
Read appraisal →Current opinion in anaesthesiology
Real-time, artificial intelligence-guided intraoperative resuscitation and fluid management in trauma anesthesia
PURPOSE OF REVIEW: To synthesize recent advances in intraoperative resuscitation for trauma surgery, including fluid composition, transfusion thresholds, and coagulopathy management, and to identify emerging directions that address persistent gaps in precision. Particular attention is given to prospective evidence, as forward-looking evaluations better capture real-world performance, workflow integration, and clinical impact, culminating in the integration of artificial intelligence and machine learning as the next stage of innovation. RECENT FINDINGS: Major trials over the past 5 years have refined evidence for balanced transfusion ratios, restrictive transfusion thresholds, and the transition from crystalloid to hemostatic and physiology-guided strategies. However, outcome variability underscores the need for individualized, data-driven resuscitation. Early prospective machine learning evaluations - along with the US Food and Drug Administration-cleared point-of-care systems such as APPRAISE-HRI - demonstrate that multimodal physiologic modeling can predict hemorrhage and fluid responsiveness as accurately as expert clinicians, while offering real-time monitoring and guidance. SUMMARY: The field is shifting from protocol-based to precision-guided trauma resuscitation. Future progress will rely on randomized-controlled-trial-validated, adaptive, human-in-the-loop artificial intelligence workflows that integrate continuous physiologic data with clinical judgment to enhance the timing, composition, and safety of intraoperative fluid and transfusion therapy.
4 Apr 2026
Read appraisal →IEEE transactions on bio-medical engineering
Explainable Prediction of ICU Transfer in Acute Pancreatitis: A Neural Network Model With SHAP Interpretability for Clinical Decision Support
OBJECTIVE: Acute pancreatitis (AP) is a life-threatening disorder commonly observed in emergency departments. Patients with acute pancreatitis may necessitate transfer to the intensive care unit (ICU) if standard treatments prove ineffective. The development of a machine learning (ML) model that can precisely forecast the necessity for ICU admission in patients with acute pancreatitis might dramatically enhance in-hospital healthcare for patients. METHODS: For this study, data were extracted from the MIMIC-III Clinical Database Care-Vue subset (MIMIC-III v 1.4), Medical Information Mart for Intensive Care-IV (MIMIC-IV v 3.1), and eICU Collaborative Research Database (v 2.0). Fifteen features were identified through Boruta's algorithm, Least Absolute Shrinkage and Selection Operator (Lasso), and Recursive Feature Elimination (RFE) utilizing the XGBoost. RESULTS: Seven machine learning models, including Support Vector Machine (SVM), K-Nearest Neighbors (KNN), and Neural Network (NNET), etc. were developed based on these features. The neural network approach demonstrated the highest reliability, attaining an AUC of 0.891, sensitivity of 0.852, and specificity of 0.767 in the test set. Meanwhile, an interpretability assessment of the most robust models was performed utilizing SHapley Additive exPlanations (SHAP) to prioritize feature importance and elucidate the final model. This model has been deployed on a web platform: https://icupredict.shinyapps.io/shiny6/. CONCLUSIONS: The neural network model effectively predicted whether patients with AP would be transferred to the ICU, demonstrating optimal performance. SIGNIFICANCE: We developed an interpretable ML model for prediction of ICU admission in AP patients. It provides clinicians with a reliable tool for early identification and treatment.
4 Apr 2026
Read appraisal →Anaesthesia, critical care & pain medicine
Hemodynamic phenotyping 4.0.
The concept of integrating hemodynamic variables to define specific profiles or phenotypes has been established for decades. Describing hemodynamic phenotypes plays a key role in educating healthcare professionals about cardiovascular physiology, enhancing the understanding of shock mechanisms, and informing treatment strategies. Recently, two notable innovations have emerged to support bedside identification of hemodynamic phenotypes: machine learning (ML) algorithms and visual decision support tools. When it comes to "small data," such as a limited set of hemodynamic variables, ML algorithms may not be essential for data integration or interpretation. In addition, the hemodynamic phenotypes identified by ML techniques often mirror traditional textbook profiles, though occasionally with inconsistencies that may impact patient safety. This raises valid questions about the need to integrate complex and proprietary ML algorithms for bedside hemodynamic assessment. By contrast, visual tools leverage clinicians' innate ability to process graphical information rapidly, improving the understanding of cardiovascular physiology and enabling recognition of hemodynamic profiles at a glance. As such, they may offer a practical, accessible, and cost-effective alternative to ML-based solutions. Future studies comparing the clinical impact of visual versus ML-driven phenotyping are now needed to guide further development and implementation.
2 Apr 2026
Read appraisal →Kidney360
Artificial Intelligence in Critical Care Nephrology: Current Applications, Emerging Techniques, and Challenges to Clinical Integration
Artificial intelligence (AI), including machine learning, deep learning, reinforcement learning, and generative AI, has the potential to advance critical care nephrology (CCN) by enhancing prediction accuracy, improving diagnostic capabilities, supporting clinical decision making, and streamlining workflow processes. Current applications in CCN include AKI prediction, nephrotoxin surveillance, intradialytic hypotension forecasting, and AI-guided dialysis and continuous KRT management, with performance often exceeding traditional models. However, the effect on patient-centered outcomes such as mortality, dialysis dependence, and cost-effectiveness remains uncertain. Emerging techniques, such as conformal prediction for calibrated risk estimates, causal inference for intervention modeling, and reinforcement learning for adaptive ultrafiltration, show promise in enhancing reliability, interpretability, and individualized care. Generative AI and large language models extend these applications to clinical documentation, reasoning, and patient education, while raising new challenges, including hallucinations, regulatory oversight, and clinician trust. Persistent barriers such as data heterogeneity, limited external validation, alert fatigue, and economic constraints hinder broad adoption. This review synthesizes the current evidence and outlines four priorities for advancing AI in CCN: ( 1 ) rigorous multicenter validation focused on clinical outcomes, ( 2 ) integration of uncertainty quantification and causal modeling into AI tools, ( 3 ) development of clinician-centered interfaces that minimize cognitive load, and ( 4 ) establishment of transparent, adaptive regulatory and governance frameworks. Realizing the promise of AI in CCN will require multidisciplinary collaboration, fairness and generalizability testing, and sustainable implementation strategies that align technologic innovation with measurable improvements in patient care.
1 Mar 2026
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