Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
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Critical care explorations
Multiagent First-Person Perspective Analysis for Leadership Assessment in Pediatric Emergency Simulations: A Feasibility Study
BACKGROUND: Conventional leadership assessments provide structured ratings but offer limited observer-independent metrics. Because leadership and teamwork are interdependent, capturing team dynamics requires multiagent, time- and space-synchronized analysis. This pilot study examined the feasibility of applying multiagent, spatiotemporally synchronized first-person perspective analysis (FPA) in emergency simulations. METHODS: This exploratory simulation study was conducted in a real patient-care room within the PICU of our institution. Two physicians-a critical care specialist (L1) and a pediatric resident (L2)-each completed one scenario as team leader. Leadership behaviors were evaluated using the Ottawa Global Rating Scale, focusing on Situational Awareness and Communication. Wearable smart glasses recorded first-person video and gaze data, enabling identification of fixations within five predefined areas ("patient," "member," "device," "screen," and "unknown"). Eye-contact events were quantified using face detection based on You Only Look Once, version 8, a deep learning-based object detection model, combined with gaze-vector estimation, and analyzed in relation to the timing of verbal communication. RESULTS: Multiagent, time-synchronized FPA was implemented without device- or software-related interruption, and no critical data loss occurred. The mean analyzable session duration relative to total operating time was 77.1%, and the mean percentage of frames excluded from object tracking was 29.3%, primarily due to target objects being outside the field of view. As secondary, illustrative findings, Ottawa Global Rating Scale scores indicated that both leaders were rated within the competent range. FPA further showed that both leaders spent approximately 80% of the scenario fixating on predefined relevant areas (L1: 599/731 s; L2: 565/693 s). Greater patient-directed fixation and balanced gaze transitions were observed in L1, whereas L2 showed prolonged fixation within nonspecific areas. L1 also established eye contact with team members more frequently during direct orders or information sharing. CONCLUSIONS: This study demonstrates the feasibility of multiagent, time-synchronized FPA for extracting gaze-based behavioral information relevant to leadership assessment in emergency simulations.
14 June 2026
Read appraisal →Critical care explorations
External Validation, Recalibration, and Extension of a Prediction Model of Early Acute Kidney Injury in Critically Ill Children Using Multicenter Data
BACKGROUND: Acute kidney injury (AKI) is common in critically ill children and is associated with high morbidity and mortality. Risk prediction models designed for clinical decision support implementation can facilitate early identification and proactive mitigation of AKI risk. Existing models have primarily been validated using single-center data, partly because of the lack of appropriately detailed multicenter datasets. OBJECTIVE: To determine the performance of a single-center model to predict new AKI at 72 hours of ICU admission in children across two multicenter datasets and refine this model to improve prediction performance while maintaining acceptable alert burden. DERIVATION AND VALIDATION COHORTS: We analyzed two datasets: the Pediatric Learning Health System Network-Virtual Pediatric Systems (PEDSNET-VPS) dataset, created through the linkage of PEDSnet electronic health record (EHR) extraction with VPS (LLC, http://www.myvps.org), and the PICU Data Collaborative dataset, created through EHR extraction and harmonization from eight participating institutions. We divided each dataset into a derivation and test split. PREDICTION MODEL: We first recalibrated an existing single-center model and measured discrimination (area under the receiver operating characteristic curve [AUROC] and area under the precision-recall curve [AUPRC]) and performance at multiple cutpoints. We next added features available at 12 hours of ICU admission, optimizing by precision and recall. We measured discrimination and performance at multiple cutpoints and identified the features contributing most to the risk score. RESULTS: In total we analyzed 186,540 ICU admissions. We found early AKI by serum creatinine criteria within 72 hours of admission in 2.2-2.7%. Initial recalibration of an existing single-center model demonstrated poor discrimination (AUROC 0.65-0.78; AUPRC 0.10-0.12). Following the addition of new features, the model had higher AUROC (0.80-0.88) and AUPRC (0.13-0.22). CONCLUSIONS: In this first use of two new multicenter datasets, we found improved performance in a model designed using features available at 12 hours of ICU admission, balancing sensitivity and precision to predict patients at risk for AKI development.
26 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
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