Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 8 appraisals
BMJ paediatrics open
The efficacy of oral sucrose for relieving lumbar puncture pain in neonates: a randomised clinical trial
OBJECTIVE: To evaluate the analgesic efficacy and physiological effects of oral sucrose during lumbar puncture (LP) in term neonates. STUDY DESIGN: This double-blind, randomised trial enrolled 60 full-term neonates undergoing LP. Participants were randomly given 2 mL of 25% oral sucrose or sterile water 2 min before the procedure. The primary outcome was pain score change from baseline via the Neonatal Infant Pain Scale (NIPS). Secondary outcomes included changes in heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO₂). Measurements were taken at baseline, 1 min, and 3 min post-LP. RESULTS: The sucrose group showed significantly smaller changes in NIPS scores at 1 min (1.0 vs 5.0, p<0.001) and 3 min (0.0 vs 4.0, p<0.001), along with smaller HR increases (p=0.012) and SpO₂ decreases (p=0.023) at 1 min post-procedure. Clinically significant tachycardia (HR >160 bpm) occurred in 40% of controls vs 13.3% of sucrose-treated infants (p=0.045), and desaturation (SpO₂ <90%) in 26.7% of controls vs 6.7% of the sucrose group (p=0.038). CONCLUSION: A 2 mL dose of 25% oral sucrose administered 2 min prior to LP is a safe and effective intervention that significantly reduces behavioural and physiological markers of pain in term neonates during the immediate post-procedural period.
1 June 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 →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 →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 →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 →Intensive Care Med
Critical care management of the patient with pharmaceutical poisoning
Poisonings account for up to 10% of admissions to intensive care units and represent a common yet complex challenge in critical care. While most patients recover with supportive care alone, a significant proportion require targeted interventions and advanced organ support. This state-of-the-art review provides a practical, evidence-based guide to manage pharmaceutical poisoning in the intensive care unit, with emphasis on real-world applicability for intensivists. It highlights toxicant-specific considerations for early resuscitation, structured by the ABCDE approach. Essential principles of the diagnostic workup are also summarized. In addition, the review offers actionable guidance on when and how to escalate care, moving from supportive measures to specific interventions including gastrointestinal decontamination, extracorporeal toxicant elimination, antidote therapy, and rescue strategies such as intravenous lipid emulsion and extracorporeal membrane oxygenation. Key algorithms and decision pathways-such as the diagnostic evaluation, ABCDE-based stabilization, gastrointestinal decontamination, and extracorporeal elimination approaches-are presented with visually structured figures. A comprehensive table provides an overview of the most relevant antidotes used in critical care, including indications and dosing.
1 Dec 2025
Read appraisal →Blood Rev
Advances in the critical care management for patients with hematological malignancies
Hematological malignancies (HMs) are increasingly associated with life-threatening complications requiring intensive care unit (ICU) management. Recent advancements in therapies, diagnostics, and critical care protocols have improved outcomes for these patients, yet significant challenges persist. This manuscript explores the evolving landscape of critical care in hematology, emphasizing the unique complications, management strategies, and future directions in the field. Patients with HMs are particularly vulnerable to infections, sepsis, organ dysfunction, and treatment-related toxicities such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and coagulopathies. Innovations in the management of acute respiratory failure, septic shock, and invasive fungal infections have contributed to better survival rates, yet outcomes remain suboptimal for certain high-risk groups. Furthermore, new therapies, including CAR-T cells, bispecific antibodies, and immune checkpoint inhibitors, present both opportunities and challenges in the ICU setting due to their potential toxicities. Emerging trends emphasize the importance of early ICU admission, multidisciplinary collaboration, and precision medicine in improving patient care. The integration of biomarker-driven strategies, advanced diagnostics, and artificial intelligence holds promise for optimizing therapeutic interventions and enhancing antimicrobial stewardship. Additionally, patient-centered approaches, including time-limited trials and goal-oriented discussions, aim to balance aggressive care with quality-of-life considerations. This review underscores the need for continued research to address disparities in access to care, improve long-term outcomes, and develop standardized protocols for managing critically ill hematology patients. By advancing the integration of oncology and critical care, clinicians can better navigate the complexities of modern therapies and provide holistic, evidence-based care that aligns with patient values and priorities.
1 Nov 2025
Read appraisal →Intensive Care Med
Invasive candidiasis in intensive care medicine: shaping the future of diagnosis and therapy
BACKGROUND: Invasive candidiasis (IC) remains one of the most challenging infections in critical care, contributing significantly to morbidity, prolonged organ support, and mortality among intensive care unit (ICU) patients. The clinical landscape of IC is evolving, with increasing recognition of Candida non-albicans species and other yeasts formerly classified as Candida spp., alongside emerging multidrug resistance and growing complexity in host immune profiles. OBJECTIVES: This contemporary, multidisciplinary narrative review-authored by intensivists, infectious diseases specialists, clinical microbiologists, and pharmacologists-aims to provide ICU clinicians with practical, up-to-date insights into the diagnosis and management of IC. To maintain clinical focus, the review excludes non-IC fungal infections and non-ICU patient populations. METHODS: Relevant literature and expert consensus were critically reviewed to summarize current diagnostic and therapeutic approaches for IC in critically ill patients. Emphasis was placed on pragmatic clinical application, diagnostic limitations, antifungal stewardship, and personalized therapeutic decision-making. RESULTS: Despite the availability of novel antifungal agents with improved pharmacokinetic properties, treatment success in IC depends equally on timely and accurate diagnosis and individualized, context-aware therapy. Blood cultures continue to demonstrate limited sensitivity (~40%). Non-culture assays, including β-D-glucan and molecular diagnostics, provide faster detection and high negative predictive value but suffer from low positive predictive value and inconsistent adoption in clinical practice. The absence of validated host-derived biomarkers further limits risk stratification, antifungal discontinuation decisions, and personalized care. CONCLUSIONS: Emerging antifungal agents, stewardship strategies, and multidisciplinary care models are essential to improve clinical outcomes and reduce antifungal resistance. This review underscores the need for integrated, team-based diagnostic and therapeutic approaches to close persistent gaps in IC management, ultimately promoting more effective, timely, and individualized care for critically ill patients with Candida spp.
1 Nov 2025
Read appraisal →