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To systematically evaluate and compare the diagnostic accuracy of pressure injury risk assessment tools in critically ill adult patients through a network meta-analysis.
Systematic review and network meta-analysis.
A comprehensive literature search was conducted across PubMed, Embase, Web of Science, and the Cochrane Library from inception to November 2025. Studies reporting the sensitivity and specificity of the Braden, Waterlow, Norton, Cubbin & Jackson, COMHON, and machine learning-based tools in ICU patients were included. A Bayesian network meta-analysis was performed to estimate pooled sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. The methodological quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.
51 studies involving 30,246 patients were included. The Cubbin & Jackson scale demonstrated relatively higher diagnostic accuracy in the network meta-analysis (e.g., sensitivity 0.81, specificity 0.71), although direct pooled estimates showed a different trade-off (sensitivity 0.90, specificity 0.73). According to the results from network meta-analysis, the pooled diagnostic odds ratio and the summary receiver operating characteristic curve (SORC) for Cubbin & Jackson was 11.64 and 0.74 respectively, but with wide credible intervals, indicating substantial uncertainty. Machine learning-based model and the COMHON scale also exhibited balanced performance, although estimates for COMHON were based on only three studies and should be interpreted cautiously. Substantial heterogeneity was observed across studies.
The Cubbin & Jackson scale may offer relatively better diagnostic accuracy for pressure injury risk assessment in critically ill adults compared with generic scales, possibly due to its inclusion of ICU-specific clinical indicators. However, indirect comparisons and wide uncertainty limit definitive conclusions. These findings support the use of context-specific assessment tools in the ICU, but head-to-head studies are needed to confirm any single tool as the most accurate.
by Xiaoliang Wan, Feiyao Deng, Xue Bai, Chenxi Xiang, Chuan Xu, Linxiao Qiu
Dysregulated serum chloride levels are prevalent in critically ill patients. However, their clinical impact remains unclear. This first systematic review and meta-analysis quantified the prevalence of hypochloremia and hyperchloremia, and their associations with mortality and acute kidney injury (AKI) in critically ill populations. We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies reporting hyperchloremia prevalence or outcomes in adult ICU patients until August 2025. Statistical analyses were conducted using Stata v16.0, and study quality was assessed using the Newcastle-Ottawa Scale. 34 studies (n = 175,021 patients) were included. The aggregated prevalence of hyperchloremia was 34% (95% CI [26%−43%]) and hypochloremia was 14% (95% CI [1%−28%]). Meta-analysis demonstrated that both hyperchloremia and hypochloremia were significantly associated with increased mortality, conferring a 28% (OR = 1.28, 95% CI [1.08–1.52]) and 55% (OR = 1.55%, 95% CI [1.33–1.81]) elevated risk for mortality, respectively. Crucially, a dose-response analysis revealed a non-linear relationship between serum chloride levels and mortality, confirming that the risk is independently elevated at both extremes. Furthermore, hyperchloremia was linked to an increased risk of AKI (OR = 1.40, 95% CI [1.07–1.85]). These findings establish dysregulated serum chloride as a common and clinically significant biomarker, underscoring the necessity of monitoring and managing both high and low chloride levels in critically ill patients. Future large-scale studies are warranted to validate these results and elucidate the mechanistic pathways linking chloride dysregulation to such adverse outcomes.
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