Lapsiwala B, Nathani PS, Bhalodia A
… +10 more, Rangan A, Rajpopat P, Khan F, Vaghani U, Kanagala SG, Chandramohan D, Naik R, Bali A, Vibhuti V, Desai R
Postgrad Med J
· 2026 May · PMID 41649079
·
Publisher ↗
Prediabetes affects nearly one-third of adults in the United States and is increasingly recognized as a contributor to early chronic kidney disease (CKD). This review summarizes current evidence linking prediabetes with...Prediabetes affects nearly one-third of adults in the United States and is increasingly recognized as a contributor to early chronic kidney disease (CKD). This review summarizes current evidence linking prediabetes with early kidney changes, including albuminuria, glomerular hyperfiltration, and mild renal impairment, as well as its association with increased cardiovascular risk. Large observational cohorts, such as the Chronic Renal Insufficiency Cohort, suggest an association between prediabetes and progression of proteinuria, although its independent contribution to advanced CKD remains variable. We review proposed mechanisms, including insulin resistance, low-grade hyperglycemia, altered tubulo-glomerular feedback mediated by sodium-glucose cotransporter 2 activity, inflammation, and endothelial dysfunction. Variability in diagnostic thresholds across major guidelines complicates risk stratification. Emerging biomarkers may facilitate earlier detection but require further validation. Early identification and guideline-directed lifestyle and pharmacological interventions may help mitigate CKD progression and related cardiovascular outcomes. These insights inform population-level screening, prevention, and decision-making.
Wang Q, Luo Y, Wu Y
… +5 more, Mei L, Wan F, Chen D, Du T, Liu C
Postgrad Med J
· 2026 May · PMID 41615064
·
Publisher ↗
OBJECTIVE: To develop and internally validate a practical nomogram for predicting early respiratory failure in acute pesticide poisoning and to benchmark its performance against the National Early Warning Score (NEWS). M...OBJECTIVE: To develop and internally validate a practical nomogram for predicting early respiratory failure in acute pesticide poisoning and to benchmark its performance against the National Early Warning Score (NEWS). METHODS: This retrospective cohort study included 205 acute pesticide poisoning patients admitted to a tertiary emergency department (ED) between November 2022 and April 2025. The primary outcome was respiratory failure or invasive ventilation within 48 h. Predictors were selected from initial assessment data (within 6 h) using least absolute shrinkage and selection operator regression to build a multivariable logistic model. Performance was assessed by discrimination [area under the curve (AUC)], calibration, and decision curve analysis, with specific comparison to NEWS using the DeLong test. RESULTS: Respiratory failure occurred in 55 (26.8%) patients. The final model comprised decreased level of consciousness (Glasgow Coma Scale < 15), organophosphate exposure, arterial pH, and serum creatinine. The nomogram demonstrated excellent discrimination (AUC 0.882; 95% confidence interval 0.829-0.934), statistically outperforming NEWS (AUC 0.789; P = .017). Calibration was robust (Hosmer-Lemeshow P = .503). A high-sensitivity screening threshold of 0.25 yielded a negative predictive value of 91.2%. Risk stratification effectively classified patients into low (<0.20; event rate 9.6%), intermediate (0.20-0.50; 28.2%), and high (>0.50; 78.0%) risk tiers. CONCLUSIONS: This simple four-variable nomogram provides accurate early risk assessment for respiratory failure in acute pesticide poisoning, offering superior discrimination over standard NEWS. The proposed risk stratification framework can support ED triage decisions regarding monitoring intensity and critical care resource allocation. Key messages What is already known on this topic: Existing severity scores (e.g. PSS, NEWS) are either too complex for rapid triage or lack specificity for the toxicological and metabolic risks of acute pesticide poisoning. What this study adds: This study develops and internally validates a simple four-variable nomogram (decreased level of consciousness, organophosphate poisoning, arterial pH, serum creatinine) that predicts early respiratory failure with significantly better discrimination than the standard NEWS score. How this study might affect research, practice or policy: By providing a practical three-tier risk stratification framework, this bedside tool may support emergency physicians in optimizing monitoring intensity and critical care resource allocation, pending external validation.
Verma R, Perera A, Luxton DD
… +1 more, Broadbent E
Postgrad Med J
· 2026 Jan · PMID 41609231
·
Publisher ↗
BACKGROUND: Virtual humans are embodied conversational agents that are starting to be investigated in healthcare to combat critical staff shortages. It is important to investigate their ability to deliver empathic consul...BACKGROUND: Virtual humans are embodied conversational agents that are starting to be investigated in healthcare to combat critical staff shortages. It is important to investigate their ability to deliver empathic consultations compared to human physicians. Incorporating good communication behaviours may help to build trust and adherence. AIM: This study's primary aim was to investigate the effects of clinical communication skills (good or poor) and physician type (virtual or human physician) on participants' perceptions of a brief medical consultation. DESIGN: A 2 (a virtual or human physician) x 2 (good or poor communication skills) parallel randomised controlled trial. SETTING: Community-dwelling adults recruited over social media. PARTICIPANTS: One hundred twenty-four adults aged 18 years or over. INTERVENTIONS: Participants watched a video of an actor in a medical consultation with either a virtual physician or a human physician, with either good or poor communication skills. MAIN OUTCOME MEASURES: Ratings of physician empathy, warmth, trust, competence, and adherence intention. RESULTS: Consultations with good communication skills were rated better on physician empathy, warmth, trust, competence, and adherence intention for both physician types (P < .005). The virtual physician was rated more empathetic than the human physician in the poor communication skill condition (P < .001). In addition, the actor was rated less likely to adhere to the virtual physician than the human physician (P = .010). CONCLUSIONS: Building good clinical communication skills into virtual physicians can encourage warm, trusting and competent relationships, which may improve adherence. Future research could investigate dynamic and real-world patient settings. Key messages What is already known on this topic: Good communication skills can improve patient trust and adherence in medical consultations. It is not known whether communication skills affect perceptions of virtual physicians compared to human physicians. What this study adds: Good clinical communication skills improve perceptions of physician empathy, warmth, trust, competence, and adherence intention, in virtual physicians similar to human physicians. Perceptions may favour virtual physicians compared to human physicians when they have poor communication skills. How this study might affect research, practice or policy: The study supports the use of virtual physicians with good communication skills. Three research questions-as snappy bullet points-that outline the current research questions-i.e. not the ones that you have answered but the ones that remain or have emerged as a result of your work. Will patients trust virtual physicians in real clinical consultations? Will trust in virtual physicians depend on the severity of the patient's condition? Will adherence differ between physicians and virtual physicians after real patient consultations?
Lv W, Wang S, Duan L
… +5 more, Dong Z, Zhu H, Wang G, Yu Z, Xu S
Postgrad Med J
· 2026 Jan · PMID 41609217
·
Publisher ↗
BACKGROUND: The relationship between metabolic syndrome (MetS) and colorectal cancer (CRC) remains incompletely understood, with chronic inflammation hypothesized as a potential mediator. This study aimed to investigate...BACKGROUND: The relationship between metabolic syndrome (MetS) and colorectal cancer (CRC) remains incompletely understood, with chronic inflammation hypothesized as a potential mediator. This study aimed to investigate associations among MetS, systemic inflammation biomarkers, and CRC risk, while focusing on the mediating role of inflammation. METHODS: Using data from 335 544 participants in the UK Biobank, we assessed associations between MetS, CRC risk, and six systemic inflammation biomarkers [neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and inflammatory burden index (IBI)]. Fine and Gray's competing risk model, multivariable linear regression, and Cox proportional hazards models were employed. Causal mediation analysis was used to evaluate the mediating effects of inflammation biomarkers. RESULTS: MetS was associated with increased CRC risk (HR = 1.11, 95% CI = 1.03-1.20, P = .007), with central obesity and hyperglycemia showing the strongest associations. Five inflammation biomarkers (NLR, PLR, SII, SIRI, and IBI) were positively associated with both MetS and CRC risk. Mediation analysis revealed that these biomarkers partially mediated the MetS-CRC relationship, with IBI accounting for the largest mediating effects (16.6%). CONCLUSION: This study confirms that both MetS and systemic inflammation contribute to increased CRC risk, with inflammation playing a significant mediating role. These findings provide novel insights into underlying mechanisms and highlight the potential of inflammation biomarkers, particularly IBI, for improving early CRC risk prediction in individuals with metabolic dysfunction. Key messages What is already known on this topic: Metabolic syndrome (MetS) is associated with an increased colorectal cancer (CRC) risk, but the biological pathway remains incompletely understood. Systemic low-grade inflammation has been proposed as a mediator, yet composite inflammation indices are underexplored. What this study adds: In 335 544 UK Biobank participants, MetS was associated with a higher risk of CRC (HR = 1.11, 95% CI 1.03-1.20). Five systemic inflammation biomarkers (NLR, PLR, SII, SIRI, and IBI) were associated with both MetS and CRC. Mediation analysis indicated partial mediation, with IBI contributing the largest proportion (16.6%). How this study might affect research, practice, or policy: Incorporating systemic inflammation indices, particularly IBI, may improve early risk stratification for CRC among individuals with MetS. These findings support the development of prevention strategies targeting low-grade inflammation, while guiding future mechanistic and translational research.
Postgrad Med J
· 2026 May · PMID 41607064
·
Publisher ↗
BACKGROUND: Chronic nonspecific low back pain (NLBP) is a highly prevalent musculoskeletal disorder that severely compromises lumbar function and diminishes the quality of life among affected individuals. This study was...BACKGROUND: Chronic nonspecific low back pain (NLBP) is a highly prevalent musculoskeletal disorder that severely compromises lumbar function and diminishes the quality of life among affected individuals. This study was designed to evaluate the therapeutic efficacy of Tuina and Baduanjin exercises in the management of NLBP. METHODS: This study enrolled patients diagnosed with NLBP who received treatment at our hospital from October 2021 to October 2023. A total of 119 eligible patients were randomly allocated into three groups: Tuina, Baduanjin, and Combined (Tuina + Baduanjin). The primary outcomes were measured using the McGill Pain Questionnaire (MPQ) to assess pain intensity, the Japanese Orthopaedic Association (JOA) scale to evaluate lumbar function, and the SF-36 scale to determine quality of life (QoL). Assessments were performed at baseline, immediately post-intervention, and at 3-month and 6-month follow-ups. RESULTS: A total of 119 patients with NLBP were included in the analysis. The results indicated that both Tuina and Baduanjin interventions were effective in alleviating pain intensity, improving lumbar function, and enhancing QoL in patients with NLBP. The combined intervention group (Tuina + Baduanjin) demonstrated significantly superior therapeutic effects compared to either Tuina or Baduanjin alone. Moreover, at the 3-month and 6-month follow-up evaluations, the combined treatment group maintained more pronounced improvements in pain relief, functional recovery, and QoL compared to the single-intervention groups. CONCLUSION: The findings of this study suggest that the integration of Tuina and Baduanjin represents a potentially effective therapeutic approach for managing NLBP, warranting further exploration for broader clinical application. Key messages What is already known on this topic: Chronic nonspecific low back pain (NLBP) is a common musculoskeletal condition that significantly impairs lumbar function and negatively impacts the quality of life of those affected. The therapeutic effectiveness of Tuina and Baduanjin exercises as interventions for managing NLBP remains unclear. What this study adds: The findings indicate that both Baduanjin and Tuina serve as efficacious non-pharmacological approaches. When employed in combination, they exhibit superior efficacy in mitigating low back pain, augmenting lumbar function, and elevating quality of life. How this study might affect research, practice, or policy: Our findings imply that the integration of Baduanjin and Tuina in clinical settings could potentially optimize therapeutic results.
Rajakumar HK, Sankaran KA, Ashok MP
… +1 more, Rachoori S
Postgrad Med J
· 2026 May · PMID 41591890
·
Publisher ↗
BACKGROUND: Peer review is central to maintaining scientific quality and helps editors make decisions. However, the volume of scientific publications continues to rise, placing pressure on the peer review system. With th...BACKGROUND: Peer review is central to maintaining scientific quality and helps editors make decisions. However, the volume of scientific publications continues to rise, placing pressure on the peer review system. With the rise of generative AI, its role in supporting peer review is gaining attention. This study aims to compare human-written and AI-generated peer review reports. METHODS: We analysed 398 peer review reports linked to 119 research articles published in BMJ Open in 2024. Publicly available reports and manuscripts were included. Editorials, corrections, and protocols were excluded. AI reports were generated using ChatGPT. All reports were anonymized and assessed by two independent reviewers. We conducted a hybrid thematic analysis. Frequencies of themes were calculated and compared by reviewer type. For quantitative comparison, we used the Mann-Whitney U test to assess differences in review quality scores and Fisher's exact test to compare the distribution of themes. All analyses were conducted using R software. RESULTS: Human reviewers gave more detailed and diverse comments. They addressed deeper issues like interpretation, originality, and applicability. AI reviews covered more sections but focused on routine or structural elements. AI outperformed slightly in format-related domains. Co-occurrence analysis showed human reviews linked diverse themes, while AI comments were structurally clustered. Shannon Index confirmed that human reviews were more thematically diverse. CONCLUSIONS: AI can support peer review by screening for basic errors. However, it lacks insight, critical judgment, and contextual awareness. Human input remains essential for meaningful review. Review-specific AI tools that preserve confidentiality are needed for future integration.
Saz-Lara A, Del Saz-Lara A, Lever-Megina CG
… +4 more, Valladolid-Ayllón S, Tébar-García D, Galán-Moya EM, Cavero-Redondo I
Postgrad Med J
· 2026 Jan · PMID 41569124
·
Publisher ↗
PURPOSE: The aim was to evaluate the association between homocysteine levels and arterial stiffness in the adult population. METHODS: Scopus, Web of Science, and PubMed databases were searched from their inception to Nov...PURPOSE: The aim was to evaluate the association between homocysteine levels and arterial stiffness in the adult population. METHODS: Scopus, Web of Science, and PubMed databases were searched from their inception to November 30, 2024. The DerSimonian and Laird method was used to calculate pooled odds ratio (OR) estimates and 95% confidence intervals (95% CIs) of the associations between homocysteine levels (plasma and serum homocysteine) and arterial stiffness in the adult population. RESULTS: Finally, 17 studies were included in the systematic review, and 16 studies were included in the meta-analysis, and included a total of 31 049 subjects. Our findings provide evidence supporting the associations between plasma homocysteine levels and arterial stiffness (OR: 2.06; 95% CI: 1.50, 2.82) and between serum homocysteine levels and arterial stiffness (OR: 1.76; 95% CI: 1.17, 2.65) in the adult population. CONCLUSION: For each μmol/L unit increase in homocysteine levels, the risk of arterial stiffness increased by 106% for plasma homocysteine and by 76% for serum homocysteine. These findings are of clinical importance for understanding the underlying mechanisms involved in vascular dysfunction to establish preventive strategies in the cardiovascular setting.
Postgrad Med J
· 2026 May · PMID 41563077
·
Publisher ↗
Recent advancements in cancer therapy have led to the emergence of innovative approaches that offer new hope to patients. This review provides a comprehensive overview of the latest cutting-edge technologies and strategi...Recent advancements in cancer therapy have led to the emergence of innovative approaches that offer new hope to patients. This review provides a comprehensive overview of the latest cutting-edge technologies and strategies in cancer treatment, including clinically approved therapies and experimental modalities in preclinical or early clinical development, with a focus on their potential to improve patient outcomes. We examined next-generation therapies, including personalized immunotherapies, targeted molecular treatments, gene editing approaches, and artificial intelligence-driven strategies. By evaluating the current landscape of these therapies, we highlighted their benefits, limitations, and future directions. The integration of these advanced modalities into clinical practice holds promise for enhancing their efficacy, reducing side effects, and ultimately transforming cancer care.
OBJECTIVE: To review evidence from randomized trials assessing the effects of preoperative double-dose oral carbohydrates in patients undergoing elective digestive system surgery. METHODS: China Biomedical Literature Dat...OBJECTIVE: To review evidence from randomized trials assessing the effects of preoperative double-dose oral carbohydrates in patients undergoing elective digestive system surgery. METHODS: China Biomedical Literature Database, the Cochrane Library, Ovid Technologies, PubMed, Web of Science, Wanfang, China Science and Technology Journal Database and China National Knowledge Infrastructure were searched from inception to March 2024, with Revman5.4 for analysis. RESULTS: Fifteen trials involving 1354 patients showed that compared with the preoperative fasting or placebo group, double-dose carbohydrates improved insulin levels [mean difference (MD) = -4.14; 95%CI = -5.50, -2.78; P < .00001] and reduced insulin resistance (MD = -1.02; 95%CI = -1.48, -0.57; P < .0001). Perioperative hunger, thirst, nausea, vomiting, and PONV were mitigated, though no significant variations on blood glucose level (MD = -0.17; 95%CI = -0.45, 0.11; P = .24). CONCLUSION: Preoperative double-dose oral carbohydrates may be a safe and feasible approach for digestive system surgery.
Postgrad Med J
· 2026 May · PMID 41556417
·
Publisher ↗
BACKGROUND: The association of body fat distribution markers with cardiovascular (CV) outcomes is not established among older adults. METHODS: 939 adults from the Glucose Intolerance, Obesity, and Hypertension study, wer...BACKGROUND: The association of body fat distribution markers with cardiovascular (CV) outcomes is not established among older adults. METHODS: 939 adults from the Glucose Intolerance, Obesity, and Hypertension study, were followed for a mean follow-up of 13 years (IQR 8). Nine fat-distribution markers were evaluated for their association with ischemic changes on ECG, and mortality. Multivariable regression models were used, and their performance was assessed using receiver operating characteristic (ROC) curves and net reclassification improvement (NRI) analysis. RESULTS: Mean baseline age was 72.3 ± 7 years and 471 (49%) were females. Upper quintiles (Q4-5) of weight-adjusted waist index (WWI) were associated with 1.8 (95%CI: 1.1-2.9, P = .01) greater odds for ischemic ECG changes. During follow-up, 466 (48.4%) participants died, 179 (38.4%) from CV causes. The WWI was the strongest predictor of both all-cause (HR = 1.4, 95%CI: 1.1-1.7, P = .002) and CV mortality (HR = 1.7, 95%CI: 1.2-2.3, P = .0031). ROC analysis showed better predictive ability for WWI (AUC = 0.442, 95%CI: 0.4-0.5, P = .003), and NRI analysis revealed that WWI outperformed other markers, correctly reclassifying 36% (95%CI: 0. 2-0.5, P = .01) and 32% (95%CI: 0.1-0.5, P < .001) of participants for all-cause and CV mortality respectively, compared with Body mass index (BMI)-based model. CONCLUSIONS: WWI showed the strongest association with mortality and should be considered the preferred marker for identifying abnormal fat distribution, potentially replacing BMI. Key messages What is already known on this topic: Body mass index (BMI) correlates poorly with visceral fat yet data on which body fat distribution markers is the strongest predictor of cardiovascular (CV) morbidity and mortality is lacking among older adults. What this study adds: Weight adjusted waist index (WWI) was the strongest predictor of ischemic ECG changes, all-cause and CV mortality, outperforming BMI. How this study might affect research, practice or policy: WWI should be considered the preferred marker for identifying abnormal fat distribution, screening individuals at risk and guide medical intervention for weight reduction, potentially replacing BMI.
Kamrul-Hasan ABM, Chatterjee S, Nagendra L
… +2 more, Dutta D, Pappachan JM
Postgrad Med J
· 2026 May · PMID 41536268
·
Publisher ↗
A systematic review and meta-analysis of real-world studies on tirzepatide is essential to strengthen evidence of its effectiveness in improving glycated hemoglobin (HbA1c) and body weight in patients with type 2 diabete...A systematic review and meta-analysis of real-world studies on tirzepatide is essential to strengthen evidence of its effectiveness in improving glycated hemoglobin (HbA1c) and body weight in patients with type 2 diabetes. 13 real-world studies (N = 89 296; duration 3-18 months) with moderate to serious bias revealed a mean HbA1c reduction of 0.91% (95% confidence interval [CI]: -1.04 to -0.79), weight loss of 9.7 kg (95% CI: -14.05 to -5.35), and body mass index decrease of 2.09 kg/m2 (95% CI: -3.27 to -0.92). Overall, 64% of tirzepatide users reached HbA1c <7%. Furthermore, tirzepatide lowered HbA1c (mean difference [MD] -0.38%; 95% CI: -0.44 to -0.33) and body weight (MD -6.27 kg; 95% CI: -9.22 to -0.33) more than the control. 47%, 23%, 9%, and 4% of tirzepatide users lost ≥5%, ≥10%, ≥15%, and ≥ 20% of their baseline weight, respectively. Tirzepatide's effects on HbA1c and weight in observational studies support clinical trial findings.
Postgrad Med J
· 2026 Jan · PMID 41527827
·
Publisher ↗
INTRODUCTION: In 2024, the UK Foundation Programme Office introduced Preference Informed Allocation (PIA) to replace the Educational Performance Measure and Situational Judgement Test (SJT) for allocating Foundation Year...INTRODUCTION: In 2024, the UK Foundation Programme Office introduced Preference Informed Allocation (PIA) to replace the Educational Performance Measure and Situational Judgement Test (SJT) for allocating Foundation Year 1 (FY1) posts. This study evaluates FY1 doctors' perceptions of PIA's fairness and effectiveness. METHODS: A nationwide survey was distributed to FY1 doctors following induction (n = 9702 eligible). Perceptions on PIA fairness, SJT removal, and Specialised Foundation Programme (SFP) allocation were collected using a five-point Likert scale (1 = strongly disagree, 5 = strongly agree). Quantitative data were analysed using non-parametric statistics, and free-text responses were examined using reflexive thematic analysis. RESULTS: A total of 1340 FY1s responded (13.8%), representing graduates from 56 medical schools. Overall, 75.2% received their first-choice foundation school, and 91.5% were placed within their top five. Most respondents disagreed that PIA was equitable (median 2 [IQR 1-3]) or should be used for SFP allocation (median 2 [IQR 1-3]), but agreed they were pleased not to have taken the SJT [median 4 (IQR 3-5)]. UK trained graduates and younger, white respondents viewed PIA less favourably than international, older, and minority-ethnic graduates. Thematic analysis emphasized loss of perceived control, calls for greater transparency, and preferences for merit-based or hybrid allocation models. CONCLUSIONS: While PIA maintained high first-choice placements, concerns about fairness were prominent, particularly among UK graduates. Many respondents favoured reintroducing merit-based components. Continued evaluation is needed to ensure a fair, transparent, and acceptable allocation process for future graduates. Key messages What is already known on this topic: The UK Foundation Programme Office replaced performance-based allocation with preference informed allocation (PIA) in 2024, aiming to improve fairness, reduce stress, and align placements with applicant preferences. However, graduate perceptions of this change have not been fully explored. What this study adds: Most respondents disagreed that PIA was a fair allocation system and opposed its use for the specialized foundation programme, particularly younger, white, and UK graduates. Many expressed preferences for reintroducing merit-based elements, such as a standardized clinical examination. How this study might affect research, practice, or policy: The findings highlight the need for ongoing evaluation of the PIA system to ensure fairness, transparency, and acceptability among medical graduates, and may help inform future postgraduate allocation reforms.
Wang X, Lou L, Kang C
… +12 more, Ren G, Luo H, Wang X, Liang S, Xia M, Ning B, Lv Y, Kang X, Li J, Zhao L, Fan D, Pan Y
Postgrad Med J
· 2026 May · PMID 41524737
·
Publisher ↗
BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is intricate and necessitates comprehensive training. The conventional hands-on approach in ERCP training may not be essential for improving trainee perfo...BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is intricate and necessitates comprehensive training. The conventional hands-on approach in ERCP training may not be essential for improving trainee performance or ensuring procedure safety. We hypothesized that hands-off assistance would be non-inferior to hands-on assistance in terms of cannulation success by trainees during ERCP training. METHODS: A total of 770 patients with native papilla were randomized to either the hands-off (intervention, n = 389) group, where trainers offered verbal guidance via teleguidance using real-time endoscopic and fluoroscopic feeds, or the hands-on (control, n = 381) group, where trainers provided on-site verbal and restrictive hands-on assistance. Eight trainees with preliminary cannulation experience were involved. The primary outcome was the successful cannulation rate within 10 min by trainees. ITT analysis was performed and non-inferiority was established if the lower bound of the 95% confidence interval for the difference in success rates exceeded -10%. RESULTS: Cannulation success rates were nearly identical (222/389, 57.1% vs. 218/381, 57.2%; absolute difference - 0.1%, 95%CI -7.1% to 6.8%; noninferiority P = .002). There was no difference in total cannulation time and attempts between the two groups. Verbal instruction and performance scores were comparable between the two groups. The incidence of adverse events was 8.2% (32/389) vs. 9.2% (35/381) (P = .73), including pancreatitis (5.7% vs. 6.8%), bleeding (1.3% vs. 0), and cholangitis (2.1% vs. 2.6%) (all P > .05). Trainers in the hands-off group received minimal radiation exposure. CONCLUSIONS: The hands-off training showed non-inferior effectiveness and safety to the hands-on training. The alternative method can be integrated into the traditional ERCP training. Key messages What is already known on this topic: Conventional endoscopic retrograde cholangiopancreatography (ERCP) training relies heavily on direct, hands-on supervision by experienced endoscopists to guide trainees during procedures. While teleguidance (remote supervision using real-time imaging) has been proposed as a potential alternative, robust evidence comparing its effectiveness and safety to traditional hands-on assistance has been lacking. What this study adds: This randomized trial demonstrates that hands-off assistance using teleguidance is non-inferior to hands-on assistance for trainee cannulation success rates (57.2% vs. 57.1%) and overall patient safety (complication rates 8.2% vs. 9.2%). It also significantly reduces radiation exposure for trainers without increasing trainees' fluoroscopy time or compromising procedural outcomes. How this study might affect research, practice, or policy: The findings support integrating hands-off training via teleguidance into ERCP curricula, offering a viable alternative that maintains trainee performance while reducing trainer radiation risk. This approach could expand training capacity, particularly in settings with limited expert availability, and prompts further research into optimizing remote supervision for complex cases and long-term competency assessment.