Critical Care Medicine

Background: Capillary refill time (CRT) is an increasingly endorsed bedside perfusion marker in septic shock.Publicly available intensive care unit (ICU) databases such as MIMIC-IV and eICU-CRD enable large-scale multi-database research, but the cross-database comparability of CRT operationalization has not been systematically examined. Methods: We conducted a retrospective, descriptive, cross-database methodological analysis of adult ICU stays in MIMIC-IV v3.1 (2008-2022) and eICU-CRD v2.0 (2014-2015). CRT availability, definitional thresholds, recording patterns and time windows, bilateral measurement consistency, and selection bias in the CRT-documented population were characterized descriptively. Results: Among 94,458 MIMIC-IV and 200,234 eICU-CRD adult ICU stays, CRT availability differed markedly:79.85% of MIMIC-IV stays had at least one CRT record within the first 24 hours, versus 6.35% of eICU-CRD stays across the entire ICU stay, a 73.5-percentage-point gap. The abnormality threshold was 3 seconds in MIMIC-IV and 2 seconds in eICU-CRD. Among CRT-available MIMIC-IV stays, the mean number of CRT records in the first 24 hours was 7.0 (median 6, interquartile range (IQR) 4-10); 99.6% had bilateral records, with 99.4% left-right agreement (Cohen's kappa 0.914). The temporal distribution of CRT records was strikingly similar between databases: only 28.7% of MIMIC-IV and 29.1% of eICU-CRD records occurred within 24 hours of ICU admission (including pre-admission records), with roughly 71% in both databases recorded later in the stay. In eICU-CRD, the CRT-documented population had higher illness severity than the undocumented population (Acute Physiology and Chronic Health Evaluation (APACHE) IV 60.0 versus 54.4; standardized mean difference 0.21), consistent with selection by indication. Structured peripheral perfusion index fields were unavailable in both databases. Conclusions: CRT operationalization differs fundamentally across MIMIC-IV and eICU-CRD in availability, definitional thresholds, recording patterns, bilateral structure, and patient selection. Cross-database CRT research should explicitly declare definitional heterogeneity, avoid pooling across thresholds, and treat sparsely documented subsets as selected populations. Selection bias was evident in both databases, in opposite directions. Severity-score-based comparison was possible only in eICU-CRD. Standardized common data elements for bedside perfusion assessment are needed to make cross-database CRT research valid by design.

Background: When intravenous insulin is stopped in critically ill patients, the basal insulin dose that balances rebound hyperglycemia against hypoglycemia is uncertain, because randomized trials were small and not designed to quantify this trade-off. We examined how the first glargine dose, relative to the preceding intravenous insulin requirement, was associated with both outcomes. Methods: In this retrospective cohort study of the Medical Information Mart for Intensive Care IV database (2008-2022), we included transitions from intravenous insulin infusions of at least 6 hours to subcutaneous glargine in adults without diabetic ketoacidosis or hyperosmolar hyperglycemic state. The exposure was the ratio of the first glargine dose to 24 times the mean infusion rate over the final 6 hours. The primary outcomes, rebound hyperglycemia (glucose >180 mg/dL within 24 hours) and hypoglycemia (glucose <70 mg/dL within 48 hours) during intensive care unit follow-up, were analyzed with multivariable Cox models after multiple imputation. Results: Among 6,220 transitions in 5,924 patients (87.5% after cardiac surgery), the median ratio was 0.41 (interquartile range 0.30-0.46). Kaplan-Meier cumulative incidences were 44.4% for rebound hyperglycemia (2,109 events) and 6.4% for hypoglycemia (211 events). Each 0.1 increase in the ratio was associated with less rebound hyperglycemia (hazard ratio 0.96, 95% confidence interval 0.93-0.99) and more hypoglycemia (1.11, 1.04-1.18), consistently across 21 sensitivity analyses. Rebound within the first 6 hours (57.6% of events) was not associated with the ratio (0.99, 0.95-1.02), whereas later rebound was (0.91, 0.86-0.96). Standardized to the cohort, a ratio of 0.60 versus 0.40 corresponded to 2.7 (0.6-4.9) fewer rebound and 1.7 (-0.2 to 3.5) more hypoglycemia episodes per 100 transitions. In secondary analyses, rebound was less frequent with glargine given at least 2 hours before discontinuation (0.86, 0.77-0.96) and more frequent with an oral diet (1.49, 1.30-1.71). Conclusions: In critically ill adults, mostly after cardiac surgery, higher glargine doses relative to the preceding intravenous requirement were associated with less rebound hyperglycemia after the first 6 hours and more hypoglycemia, a gradual trade-off. Which basal fraction is preferable depends on the weight given to each outcome; a randomized trial including the guideline-implied fraction of about 0.30 is warranted.

OBJECTIVE: Sepsis-associated encephalopathy (SAE) and sepsis-associated delirium (SAD) lack confirmatory laboratory tests or biomarkers. We evaluated whether the Th17/interleukin (IL)-17 axis or neuroglial-injury biomarkers reflect acute brain dysfunction beyond systemic inflammation and whether biomarker profiles differ between these phenotypes. DATA SOURCES: EMBASE, MEDLINE/PubMed, and the Cochrane Library from inception to August 1, 2026, supplemented by backward and forward citation searching, following PRISMA 2020. STUDY SELECTION: Observational studies of adults with sepsis classified by SAE or SAD status and reporting circulating biomarker concentrations by neurological group or biomarker-outcome associations. Eighteen studies (2,388 participants; 1,863 with sepsis) were included. DATA EXTRACTION: Two reviewers independently extracted study, phenotype, assay, and outcome data. Risk of bias was assessed with the Newcastle-Ottawa Scale and certainty with GRADE. DATA SYNTHESIS: Random-effects models pooled standardized mean differences (SMDs) separately against non-septic and septic controls and odds ratios (ORs) for biomarker-outcome associations. IL-6 was the only mediator elevated in both comparative frameworks and associated with outcomes (non-septic controls: SMD, 0.54 [0.25-0.82]; septic controls: SMD, 1.05 [0.51-1.59]; OR, 1.85 [1.50-2.29]). S100B, neuron-specific enolase, IL-10, tumor necrosis factor; and interferon-gamma; were elevated versus septic controls, whereas IL-17 was modestly elevated only versus non-septic controls (SMD, 0.37 [0.01-0.73]). The IL-6 septic-control effect was concentrated in SAE (p<0.0001) and remained robust in leave-one-out and risk-of-bias sensitivity analyses. Certainty was low to very low, and all 14 computable prediction intervals included the null. CONCLUSIONS: IL-6 emerges as the leading circulating candidate biomarker of sepsis-associated brain dysfunction, while S100B and NSE capture neuroglial injury beyond sepsis. Current evidence does not establish a discriminating role for the Th17 axis. Future studies require standardized neurological phenotyping and appropriately matched septic controls to establish diagnostic value.

Background Mortality in sepsis is often considered a direct consequence of infection and organ dysfunction, although many deaths occur after withdrawal of life sustaining treatment. The clinical factors leading to these decisions and their implications for interpreting sepsis mortality are not well characterized. Methods We performed a secondary analysis of a prospective observational cohort of adults with physician adjudicated sepsis at a tertiary academic medical center. Patients who transitioned to comfort measures only (CMO) during the index hospitalization underwent structured chart review to characterize baseline health and functional status, clinical severity, care preferences, anticipated outcomes following survival, and the primary reason for CMO transition. Results Among 239 patients with adjudicated sepsis, 42 (17.6%) transitioned to CMO. These patients had substantial underlying disease, including malignancy in 76% and immunocompromised status in 62%. However, 88% lived at home before hospitalization, 52% were independent in activities of daily living, an additional 26% were partially independent, and 90% were full code on admission. Progressive multi organ failure (19%), refractory septic shock (19%), and irreversible respiratory failure (12%) accounted for half of CMO transitions, while advanced frailty (5%) and poor baseline functional status (2%) were infrequent primary reasons. Median time from admission to CMO was 16 days (IQR 7 to 33), and median time from admission to death was 18 days (IQR 11 to 35). Anticipated ventilator dependence (62%), dialysis dependence (36%), and cognitive impairment frequently influenced goals of care discussions. Overall, 38 patients died during the index hospitalization, and 35 (92%) of these deaths followed transition to CMO. Conclusions Most CMO transitions in this cohort occurred after an evolving course of severe sepsis and were driven primarily by progressive organ dysfunction and failure to recover rather than advanced frailty or poor baseline function. These findings identify failure to recover after the acute septic insult as an important clinical trajectory and highlight the need to account for treatment limitation when interpreting sepsis mortality. Understanding why some patients recover from sepsis associated organ dysfunction while others progress to irreversible organ failure may help identify patients and mechanisms for future therapeutic intervention.

Abstract Background: In patients with sepsis and pre-existing hypertension, admission findings may not adequately describe the subsequent course of circulatory support and organ dysfunction. We developed and externally validated a model to reassess in-hospital mortality risk after the first 72 hours of intensive care. Methods: This retrospective study used MIMIC-IV for development and eICU-CRD for external validation. Patients had received vasoactive agents and remained in the ICU for at least 72 hours. Static variables were combined with features from six consecutive 12-hour windows. Imputation, feature selection, model fitting, and calibration were performed within training folds during five-fold cross-validation. The final XGBoost model was applied externally without refitting. Evaluation included discrimination, calibration, decision curves, and risk stratification, with an exploratory comparison of static-only and static-plus-dynamic feature sets. Results: The development and external cohorts included 1019 and 1747 patients, with 338 (33.2%) and 516 (29.5%) deaths, respectively. Internal area under the receiver operating characteristic curve (AUC) was 0.752 (95% CI 0.720-0.784). External AUC was 0.713 (95% CI 0.687-0.739), average precision was 0.536, the Brier score was 0.185, and the calibration slope was 0.744. Mortality increased across external risk tertiles from 13.7% to 47.3%. In an exploratory feature-set comparison, the static-plus-dynamic feature set showed a 0.071 higher internal AUC than the static feature set (95% CI 0.042-0.109). Conclusions: Information accumulated during the first 72 hours supported subsequent mortality risk stratification in this selected population. The model retained moderate discrimination externally, supporting further evaluation as an adjunct to clinical reassessment. Local calibration and the clinical consequences of acting on model predictions require evaluation before routine use.

Purpose Delirium affects around 40% of intensive care unit (ICU) patients and adversely affects survival, length of stay, and cognitive recovery. Despite this, implementation of systematic clinical delirium assessments is variable. We sought to validate a point-of-care electroencephalography (EEG)-based system (Ceribell, Inc.) for the detection of delirium in the ICU. Methods In this multicenter, prospective cohort study, we monitored adult ICU patients with the Ceribell EEG system for 6-8 hours for a minimum of three days. Up to three times per day, expert clinicians assessed participants for delirium and research coordinators completed Confusion Assessment Method for the ICU (CAM-ICU) assessments, which we used to calculate CAM-ICU-7 severity scores. We compared expert clinician diagnoses with Ceribell EEG algorithm output using data from 30-minute periods surrounding each clinician assessment. Results Among 225 participants analyzed (median age: 64 years, 60% male, 21% mechanically ventilated), expert clinicians performed 857 assessments and found 24% of participants were delirious during at least one assessment. The Ceribell EEG system detected delirium with a sensitivity of 81% (95% CI: 76% to 87%) and specificity of 81% (95% CI: 78% to 84%). The continuous Ceribell EEG system score correlated with CAM-ICU-7 delirium severity scores (bootstrapped median rho 0.58, IQR: 0.54-0.62, p <0.001). Conclusion In a mixed adult ICU population, the Ceribell EEG system identified delirium with good sensitivity and specificity. Its continuous output was associated with delirium severity, highlighting its potential ability to characterize underlying physiological patterns across the clinical delirium spectrum.

Background: During emergency tracheal intubation, clinicians use waveform capnography or colorimetric carbon dioxide (CO2) detection to confirm exhaled CO2 from the endotracheal tube to determine its location. Both devices reliably yield a negative result when the tube is in the esophagus. However, in most emergency intubations the tube is correctly located in the trachea, and in this circumstance the relative diagnostic accuracy of the two devices is uncertain. If one device more often fails to detect exhaled CO2 despite correct tube placement (a false negative result), this could lead to unnecessary tube removal, repeated intubation attempts, and an increased risk of serious complications. Research Question: Among critically ill adults undergoing emergency tracheal intubation, is waveform capnography or colorimetric CO2 detection more sensitive for identifying an endotracheal tube correctly placed in the trachea? Study Design and Methods: The WAVE study is a pragmatic, prospective, paired diagnostic accuracy study conducted in emergency departments and intensive care units in the United States. The study compares waveform capnography and colorimetric CO2 detection (index tests) against a non-CO2-based reference standard for endotracheal tube location among 2,092 critically ill adults undergoing tracheal intubation. The primary outcome is the sensitivity of each index test for identifying a tube located in the trachea. The secondary outcome is specificity for identifying a tube located outside the trachea. Results: Enrollment began on April 21, 2025 and is ongoing, with completion anticipated in 2026. Interpretation: The WAVE study will provide prospective evidence comparing waveform capnography with colorimetric CO2 detection for determination of endotracheal tube location in critically ill adults. These findings may inform clinical practice and guideline recommendations regarding the optimal test of exhaled CO2 for use in the ED and ICU. Prespecifying the protocol and statistical analysis plan before completion of enrollment enhances the rigor, reproducibility, and transparency of the study.

Background: Host response and biomarker research to advance sepsis therapeutics requires well-characterized cohorts with longitudinal biospecimens across a range of hosts and infections. Automated screening based on SIRS criteria is sensitive but nonspecific and identifies more candidates than research teams can approach, sample, and follow longitudinally. We evaluated a structured enrichment review by non-physician study staff, done after automated screening in a hospital-wide prospective sepsis cohort. Methods: The CISID cohort is a prospective observational study of hospitalized patients with suspected sepsis, enrolling adults from the ED, inpatient wards, and ICUs at a tertiary academic medical center. Patients were identified through: (1) automated electronic health record screening for two or more SIRS criteria with a 24-hour lookback, documentation of microbiologic culture or PCR, and receipt of a new antibiotic; (2) a sepsis enrichment step of structured chart review by trained non-physician study staff; and (3) discussion with the primary clinical team. Enrolled patients underwent physician adjudication into four diagnostic categories. To evaluate the enrichment step, we analyzed all patients screened during a 9-week period, assigned a composite "sepsis-likely" variable (CDC Adult Sepsis Event criteria or ICD-10 code R65.20/R65.21 within 48 hours before or after screening), and assessed mortality across each stage of screening. We also assessed concordance of the composite with physician adjudication among enrolled patients. Results: From November 2023 through February 2026, 4,318 patients screened in through EHR-based automated screening; 1,220 (28%) were flagged for enrollment, and 288 were enrolled. Physician adjudication classified 209 (73%) as sepsis, 46 (16%) as infection without sepsis, 14 (5%) were classified as undifferentiated critical illness, and 19 (6.6%) as non-infectious sepsis mimics. Patients with sepsis were severely ill (median SOFA score, 9; ICU admission, 80%; shock, 48%), and 51% were immunocompromised; mortality was 14% in hospital and 27% at 90 days. In a 9-week sample of 907 screened encounters, 21% of those deferred and 70% of those flagged for enrollment met the sepsis-likely composite, a 3.3-fold increase in prevalence after structured study team review. Conclusions: A brief structured enrichment review after automated screening tripled the prevalence of EHR-based sepsis indicators among patients selected for enrollment, while concentrating enrollment efforts on roughly one-quarter of screened-in patients in this hospital-wide, all-source suspected-sepsis cohort. This approach may help prospective cohorts direct limited biospecimen resources toward patients most informative for host-response and biomarker research.

Objective: To test the hypothesis that selected SIRS and SOFA criteria measured at ICU admission have divergent associations with (1) the development of new culture-confirmed infections and (2) early empiric broad-spectrum antibiotic receipt in critically ill patients with cirrhosis. Design: Retrospective, observational study using electronic health record (EHR) data. Setting: Both community and academic ICUs within a five-hospital health system between July 2017 and December 2025. Subjects: Adult patients >18 years of age diagnosed with cirrhosis admitted to the ICU within 96 hours of hospital admission. Patients transferred from outside facilities and those with positive cultures collected >24 hours before ICU admission were excluded. Interventions: None. Measurements: Multivariable logistic regression tested the association of the most aberrant values in nine SIRS/SOFA vital sign and laboratory parameters measured during the 24 hours prior to ICU admission with (1) the development a newly positive culture collected during the 24 hours before through the 96 hours after ICU admission and (2) receipt of broad-spectrum antibiotics during the 24 hours before through the 24 hours after ICU admission. Main Results: The presence of hyperthermia, hypothermia, hypoxia, or hypotension at ICU admission was associated with both culture positivity and antibiotic receipt. The presence of leukocytosis was associated with antibiotic receipt but not culture positivity. Among patients in the 21.6% of encounters with newly positive cultures, normothermia and normal WBC were common (respectively present in 97.2% and 77.5% of encounters) and associated with antibiotic omission at ICU admission despite the subsequent development culture positivity. Conclusions: Traditional physiologic markers of infection are often absent in critically ill patients with cirrhosis who develop new culture-confirmed infections at ICU admission, possibly contributing to delayed antibiotics. There may be opportunities to improve antibiotic delivery and stewardship at ICU admission in this high-risk population.

BACKGROUND Traditional organ dysfunction classifications after severe trauma rely on binary categories (e.g., chronic critical illness [CCI] versus rapid recovery), which likely oversimplify the true heterogeneity of postinjury organ dysfunction trajectories and their underlying immune-biologic drivers. We hypothesized that severely injured trauma patients demonstrate multiple, distinct organ dysfunction phenotypes distinguished by unique immune signatures. METHODS We performed a prospective, longitudinal, observational cohort study of severely injured trauma patients at high risk for multiple organ dysfunction at a single Level 1 trauma center. Organ dysfunction was quantified daily through 28 days, death, or discharge using a trauma-specific modified Sequential Organ Failure Assessment (mSOFA) score excluding the neurologic subdomain to isolate systemic organ dysfunction from traumatic brain injury. We utilized group-based trajectory modeling to identify longitudinal mSOFA phenotypes. Plasma immune protein trajectories were compared across phenotypes using mixed-effects models with time interaction. RESULTS Sixty-nine patients were enrolled. Trajectory modeling identified five mSOFA phenotypes (c1-c5) with differences in resuscitation requirements, shock severity, and 28-day mortality, but not baseline demographics, injury severity, or early physiologic parameters. The phenotypes revealed organ dysfunction heterogeneity not fully captured by CCI/rapid recovery classification. Forty of 92 measured immune markers showed phenotype-differentiated trajectories (FDR<0.1). The most fulminant phenotype (c5) was distinguished by IL-17C, CXCL5, and CXCL6, implicating epithelial-barrier and neutrophil-trafficking mechanisms. The phenotype with highest CCI incidence (c3) was distinguished by rising CXCL9, ARTN, and TWEAK, implicating Th1 polarization and tissue-inflammation/repair signaling. The clinically distinct, older-age phenotype (c4) carried the largest differentiating signature (29 proteins), spanning renal injury/repair, endothelial activation, and adaptive lymphocyte modulation. CONCLUSIONS Organ dysfunction after severe trauma is more biologically heterogeneous than traditional clinical classifications suggest. Distinct mSOFA trajectory phenotypes correspond to distinct immune signatures, supporting separable pathobiology rather than a single axis of injury severity, with implications for phenotype-targeted precision immunomodulatory approaches in critical illness.

Objectives To examine the prevalence of interruptions during UK secondary care outpatient consultations, their association with clinician mental workload, and the strategies clinicians use to manage them. Design Nationwide cross-sectional online survey. Setting Secondary care outpatient clinics, United Kingdom. Participants A sample of 465 UK secondary care doctors across a range of grades and specialties, recruited through a medical defence organisation's network. Primary and secondary outcome measures Mental workload (NASA Task Load Index, Raw-TLX); interruption frequency; perceived cognitive impact of interruptions; task resumption difficulty; perceived social effects on colleague interactions and team cohesion; and interruption-management strategy use. Results 61.1% of clinicians reported being interrupted often or very often, and mean overall workload was high (Raw-TLX 66.2, SD 11.5). Interruption frequency, patient complexity and perceived cognitive impact were each associated with higher workload across multiple NASA-TLX subscales. In fully adjusted models, interruption frequency retained independent associations with overall workload (beta = 1.79, p = 0.004) and temporal demand (beta = 0.94, p < 0.001). Task resumption difficulty was associated with worse perceived performance (beta = -0.59, p = 0.014), while perceiving interruptions as socially positive was associated with better performance (beta = 0.75, p = 0.003) and lower frustration (beta = -1.16, p < 0.001). Years of experience showed only small effects, and self-reported strategy use (38.7%) was not consistently associated with lower workload. Exploratory natural language processing of open-text descriptions identified three strategy clusters; cognitive offloading, anticipating and preparing, and blunt responses, with distinct emotional profiles. Conclusions Interruptions were commonly reported during UK secondary care outpatient consultations and were associated with measurable cognitive and temporal burden. The perceived social framing of interruptions was independently associated with frustration and self-rated performance. Binary strategy use showed no consistent workload association, indicating a need for system-level approaches addressing interruption frequency, task resumption support and the social context of interruptions rather than reliance on individual coping.

Background Pediatric neurocritical care (PNCC) has emerged as a distinct field, and many hospitals have moved to establishing dedicated PNCC programs. How practice change is implemented within these programs is not well understood. This study had two objectives. First, we sought to understand the barriers and facilitators of practice change in PNCC from the perspectives of the multiprofessional clinicians who deliver it. Second, we sought to characterize how well the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation determinant framework captures them. Methods We conducted semi-structured interviews with a purposive sample of clinicians involved in PNCC at three U.S. academic medical centers. The interview guide was developed using i-PARIHS to organize barriers and facilitators of practice change across the innovation, recipients, context, and facilitation constructs. We applied framework analysis, combining deductive i-PARIHS, study-specific, and inductively derived categories. Two coders independently indexed the transcripts and reconciled them to consensus, with first-author adjudication. Preliminary site-level findings were validated with participants. Results We interviewed 33 clinicians: 24 physicians, 7 nurses, and 2 advanced practice providers. Most determinants of practice change mapped to existing i-PARIHS constructs, but three were not adequately captured by the framework as currently specified. The most consequential was an interprofessional authority gradient that determined whose preferences prevailed when intensive care, neurology, and neurosurgery disagreed. The other two were clinician autonomy, which served as the lens through which the acceptability of a change was judged, and the affective state clinicians bring to practice change. Receptivity depended more on recipients' values, prior experience, and capacity to absorb change into a demanding workflow. Facilitation was variable, frequently under-resourced, and dependent on credibility across professional groups. We translated these findings into three propositions linked to implementation strategies and outcomes. Conclusions Participants attributed practice change in PNCC more to the recipients of change, the multiprofessional context, and the availability of facilitation than to the strength of evidence for a given practice. i-PARIHS captured most barriers and facilitators well but may be adapted in this setting. Credible, resourced, authority-sensitive facilitation may improve the prospects for sustained practice change as institutions develop PNCC programs.

Background While overall application volume by ethnic minority doctors into UK postgraduate medical training has expanded significantly, workforce diversity varies substantially across specialties. Previous reports have suggested that doctors from certain ethnic backgrounds and international medical graduates (IMGs) experience lower likelihoods of securing training posts, but granular longitudinal evaluations across all specialty training levels and recruitment stages remained limited. Therefore, this study evaluates longitudinal trends in self-reported ethnicity and country of qualification across postgraduate medical training in England between 2021 and 2025, maps specialty representation, and tests the hypothesis that recruitment success rates differ significantly between ethnic minority and White baseline applicants. Methods We conducted a retrospective national longitudinal analysis of mandatory NHS specialty recruitment data across England from 2021 to 2025, encompassing over 300,000 applications across ST1/CT1 (entry-level) and ST3+ (higher specialty) pathways. Applicants were categorised into census-aligned broad and granular ethnic groups, alongside IMG classifications. Unadjusted odds ratios (ORs) with 95% confidence intervals were calculated using White graduates and internal sub-ethnic baselines as comparators. Specialty-level ecological correlations (Spearman's rho) were performed to evaluate whether international workforce reliance moderated ethnic recruitment disparities. Results Between 2021 and 2025, applicant volume expanded rapidly, with ethnic minority applicants and IMGs comprising numerical majorities. However, Asian and Black applicants experienced substantially lower odds of receiving training offers compared to White baseline applicants across multiple high-volume specialties (e.g., emergency medicine and anaesthetics at ST1, where Black applicants faced multi-fold reductions in success odds: OR 0.03 to 0.05, p<0.001). Granular analyses revealed notable intra-ethnic heterogeneity, including lower success among Pakistani and Bangladeshi applicants compared to Indian applicants. Furthermore, UK graduates maintained higher offer success than IMGs across most specialties. Ecological correlations demonstrated that higher international applicant reliance was moderately and significantly associated with wider recruitment disparities at higher training levels for Black applicants {rho}=-0.43, p=0.019). Conclusions Centralised medical recruitment in England exhibits some persistent ethnic and international qualification disparities despite rising application diversity. The findings highlight the necessity of disaggregating ethnic groups and addressing subjective evaluation vulnerabilities within multi-stage recruitment processes to foster equity. Trial registration: Not applicable

Background: Patient-facing AI intake chatbots can enter clinical use without regulatory review, so their errors may first surface with actual patients. Objective: To develop and pilot a remote, voice-based standardized patient (SP) method for evaluating an intake chatbot's history-taking, documentation, and patient-centeredness. Methods: Four primary care cases had Easy and Difficult variants. In Phase 1, five SPs completed 40 encounters with internal medicine residents rating portrayal fidelity. In Phase 2, SPs completed 80 encounters with a ChatGPT 4o chatbot, recorded whether critical elements were asked about and addressed satisfactorily, and rated summaries; four debriefing interviews were analyzed. In Phase 3, two blinded clinicians rated transcripts and summaries from 101 encounters (32 resident-led, 69 chatbot-led). Results: Portrayal fidelity averaged 4.52 of 5. The chatbot asked about 59.3% of critical elements in Easy versus 50.2% in Difficult variants (adjusted OR 1.49; 95% CI, 1.15 to 1.93) and addressed 73.3% versus 64.6% (OR 1.47; 1.12 to 1.93); near-ceiling summary quality did not differ. SPs reported missed information and rushed pacing. Reviewer agreement was moderate to substantial for element judgments (AC1 0.49 to 0.70) but poor for totals (ICC 0.10 and 0.21). In exploratory comparisons, residents asked about more elements (adjusted difference 12.5 percentage points; 95% CI, 7.0 to 18.1) and satisfactorily addressed more (9.2 points; 3.8 to 14.6); totals did not differ. Conclusions: SP portrayal was consistent enough for pre-clinical chatbot evaluation, and the method detected lower coverage in harder cases. Documentation ratings alone may miss conversational gaps, which require direct measurement.

Objectives: Health professions students often receive limited training on how to adjust their communication for patients whose first language is not English (LX), despite the risks for diagnosis, treatment, and patient trust. Based on Communication Accommodation Theory, we developed a brief module to improve students' awareness and knowledge of strategic communication adjustments for LX patients. Methods: We tested feasibility in a single-group, pre-post pilot study guided by the Kirkpatrick framework with undergraduate (n=22) and graduate (n=41) speech-language pathology and psychology students in Massachusetts and North Carolina. The module included instructional content, video and audio examples, interactive activities, and a podcast. Learning was assessed with knowledge checks, and self-reported facilitative and resistant accommodation with the Communication Accommodation Behavior Scale (CABS). After training, students rated their confidence and likelihood of using accommodation strategies. Results: At both sites, facilitative accommodation increased and resistant accommodation decreased significantly, with a larger decrease at the undergraduate site. Knowledge-check accuracy was high at both time points, suggesting a ceiling effect. Students reported moderate- to-high confidence in adapting their speech and high likelihood of using a learned strategy in future clinical encounters. Conclusions: A brief module can be feasibly delivered across institutions and is associated with short-term improvements in self-reported communication accommodation. Practice implications: We recommend future work evaluate whether these changes translate into clinical behavior long-term and refine knowledge-check items to better capture learning gains.

Introduction and objectives Hydrocephalus is a common complication of aneurysmal subarachnoid haemorrhage. This is one of several standard indications for the insertion of an external ventricular drain, but there are no standard guidelines for timing of extraventricular drain discontinuation in this population. Therefore, the study aims were to examine the 1) factors associated with extraventricular drain duration in aneurysmal subarachnoid haemorrhage and 2) association between extraventricular drain duration and clinical and resource-based outcomes. Methods In this single centre retrospective cohort study, data for adult patients treated in the ICU between 2015-2023 with aneurysmal subarachnoid haemorrhage and requiring an extraventricular drain were analysed. Data were extracted from both a prospective patient registry and the electronic medical record. Linear regression modelling was used to identify the factors associated with extraventricular drain duration. Measures used to examine the association between extraventricular drain duration, and the outcomes of interest included hazard ratio, relative risk, and mean differences as appropriate for a specific outcome. Results Of the participants (n=205), 68% (n = 140) were female, mean age was 60.7 (SD 13.3) years and 71% (n = 145) had a modified Fisher score of 4. Mean extraventricular drain duration was 15.3 (SD 8.6) days. The number of days mechanically ventilated and extraventricular drain challenge by clamp trial were associated with an increased duration of extraventricular drain treatment. Increased extraventricular drain duration was associated with an increased incidence of ventriculoperitoneal shunt insertion, and an increase in ICU and hospital length of stay when extraventricular drain duration exceeded 20 days. Conclusion The factors associated with an increased duration of extraventricular drain treatment were a longer duration of mechanical ventilation. The outcomes associated with an increased duration of extraventricular drain treatment were an increased incidence of ventriculoperitoneal shunt insertion, an increased incidence of ventriculitis when extraventricular drain duration exceeded 20 days, and an increase in ICU length of stay. These study findings may inform the conduct of a larger multi-centre study to examine the factors associated with duration of treatment with extraventricular drain, and outcomes associated with extraventricular drain duration.

BACKGROUND: As artificial intelligence (AI) enters clinical practice, concerns about deskilling and never-skilling make the independent assessment of clinical competence increasingly important. The AI-Standardized Clinical Examination (ASCE) uses AI to simulate and score standardized clinical encounters, potentially overcoming some of the logistical and standardization constraints of conventional objective structured clinical examinations (OSCEs). Whether it provides valid and reliable assessment at scale is unknown. METHODS: In this prospective multicenter cohort study, final-year medical students from six French medical schools completed a 10-station ASCE six weeks before the national OSCE session. GPT-4o simulated standardized clinical partners; transcripts were subsequently scored by GPT-4.1 against faculty-defined rubrics. The primary outcome was the correlation between ASCE and national OSCE scores. Secondary outcomes were inter-rater reliability of expert transcript scoring, alignment of ASCE scores with expert ratings, and internal consistency. RESULTS: Among 948 enrolled students, 588 had paired ASCE and national OSCE scores. ASCE scores were correlated with national OSCE performance (Spearman's {rho}, 0.57; 95% CI, 0.51 to 0.63), with less than 1% of residual variance attributable to center (intraclass correlation coefficient, 0.01). Eight experts scored 20 randomly selected ASCE transcripts; Krippendorff's was 0.77 overall, 0.80 for clinical skills, and 0.70 for communication and attitude skills. Adding GPT-4.1 as an evaluator reduced by 0.02, and its scores did not differ significantly from those of individual experts. Internal consistency was 0.67 across 10 stations and was projected to approach 0.80 with 20 stations. CONCLUSIONS: Scores from an examination delivered and scored by AI were associated with performance on a national high-stakes OSCE, with minimal center-level variation, tentative agreement among expert raters, and automated scores that aligned with expert ratings. These results support AI delivery and scoring of clinical examinations, with expert review of automated scores.

Background Interruptions are common in hospital outpatient departments (OPDs) and are linked to error. Many are clinically necessary, so the aim is to regulate them. Most interventions target the individual clinician. Little is known about how doctors manage interruptions in practice or what makes their strategies work. Methods Qualitative study using focus groups and interviews with 42 doctors working in UK National Health Service OPDs (19 sessions, September to November 2025). Participants were purposively sampled by clinical experience and self-reported patient complexity. Data were analysed using Framework Analysis, informed by Cognitive Load Theory and Social Identity Theory. Results We developed four themes. (1) Pre-emptive protection of attention. Doctors withdrew, signalled unavailability and set thresholds for interrupting. These depended on colleagues learning and sharing the norm, which staff rotation eroded. (2) Sharing the burden through team coordination. Designated roles and time-limited rotas moved interruptions to colleagues with capacity set aside for them and made interrupting legitimate. (3) Real-time cognitive repair. Doctors asked interrupters to wait while they secured the task, and rebuilt the consultation on return, sometimes with the patient's help. Asking a colleague to wait depended on seniority or team membership; some trainees described difficulty doing this with senior colleagues. (4) Organisational recognition as the precondition for sustainable regulation. Where supervision was built into job plans, the interruptions it generated were expected and doctors held capacity in reserve for them. Advice, vetting and telephone queries were rarely counted as work. Conclusions Each strategy served a cognitive purpose, and social and organisational conditions decided whether it was perceived to work. Interventions could make norms shared and roles explicit, count interruption work in job plans and keep routes open for junior staff to raise concerns. Evaluations should ask who is able to use them.

Background: The practice of hospitalizing emergency department (ED) patients with chest pain after ruling out acute myocardial infarction (AMI) varies widely. The long-term outcome and cost implications of this variation are uncertain. Methods: Analyzing 2007-2021 claims from a national commercial insurer, we identified 223,569 adults (18 years or older) ED visits with a principal diagnosis of chest pain without major secondary cardiopulmonary diagnoses, seen by 19,001 clinicians in 2,273 EDs. Within each ED, clinicians with the highest and lowest terciles of risk-adjusted hospitalization rates were classified as high- versus low-admitting. Primary outcomes were 30- and 180-day subsequent AMI hospitalizations. Secondary outcomes included 7-day cardiac testing, 30-day coronary intervention, and 30-day total and out-of-pocket costs. We estimated adjusted rate ratios (aRRs) and relative cost differences using generalized estimating equations, adjusting for patient and visit characteristics. Results: Patients had a mean age of 48.6 years, and 53.9% were female; measured characteristics were similar between groups. Compared with low-admitting clinicians, visits to high-admitting clinicians had higher 7-day cardiac testing (13.1% vs 10.8%; aRR 1.22, 95% CI 1.17-1.27) and 30-day coronary interventions (4.3% vs 3.8%; aRR 1.16, 95% CI 1.09-1.23). AMI hospitalization did not differ at 30 days (0.60% vs 0.60%; aRR 1.00, 95% CI 0.84-1.15) or 180 days (0.85% vs 0.87%; aRR 0.97, 95% CI 0.85-1.10). Thirty-day total costs were higher after visits to high-admitting clinicians (relative change 11.3%, 95% CI 8.8-13.8), and out-of-pocket costs $1,000 or more were more common (32.0% vs 29.6%; relative change 8.2%, 95% CI 6.1-10.3). Conclusions: Higher clinician hospitalizing tendency for ED chest pain is associated with greater downstream testing, more coronary interventions, and higher costs without lower short- or intermediate-term AMI risk. Reducing marginal admissions among high-admitting clinicians may decrease spending and practice variation with minimal impact on AMI outcomes.

Background Best practice alerts (BPAs) used in emergency departments (EDs) to identify patients with possible sepsis lack specificity and some ED patients with sepsis BPAs are discharged. We evaluated factors associated with ED discharge following a sepsis BPA and with subsequent 7-day return admissions with sepsis or infection. Methods We conducted a retrospective cohort study using an electronic health record data query from five hospitals (2022-2024). Using logistic regression, we evaluated the association of participant demographics and clinical characteristics with ED discharge and factors at the initial ED visit associated with return admission. Results Among 62,068 ED visits with a sepsis BPA, one third resulted in ED discharge. Discharged participants were younger and more often female, Black, multiracial, and/or Hispanic; they more often had an initially normal pulse, respiratory rate, blood pressure, and lactic acid than admitted participants. Discharged participants more often had a fever on arrival (adjusted odds ratio (aOR) 6.03; p<0.001) and a white blood cell (WBC) count 11,000-14,999 (aOR 4.57; p<0.001) or 15,000-19,999/uL (aOR 2.01; p<0.001). One percent of discharged participants experienced a 7-day return admission with a diagnosis of sepsis or infection, which was associated with older age, White or Asian race, diastolic hypotension, WBC count [&le;]15,000/uL or <4,000/uL, and an index visit BPA response indicating sepsis or non-response. Conclusions Return admissions among discharged ED patients with a sepsis BPA are rare. Several factors are associated both with hospital admission at the index visit and return admission, indicating a need for additional risk-stratification tools.