To evaluate the efficacy of a multimodal obstetric hemorrhage prevention algorithm in lowering the obstetric hemorrhage rate at a tertiary care center to under the national rate of 3
Surgical, anesthetic, and intensive care practices now depend on a large ecosystem of wired and wireless devices, robotic consoles, imaging and laboratory systems, and cloud infrastructure: the Internet of Medical Things and the smart operating room, which extends care beyond the physical theatre to transcontinental telesurgery. Connectivity that is useful in routine care becomes a failure mode during a cyber incident because surgical pathways depend on uninterrupted access to scheduling, imaging, electronic records, and device data. This narrative review sets out the architecture of the surgical Internet of Medical Things and the main threat categories: ransomware, supply chain and firmware compromise, wireless interception, attacks on teleoperated robotic systems, and insider or workforce-related exposure. It then examines documented incidents at the hospital, emergency, and procedural levels, together with the vulnerability profiles of robotic surgical platforms, cardiac implantable electronic devices, infusion systems, and perioperative monitors. Reported harms include cancelled admissions, interrupted cancer surgery and radiotherapy, and worse outcomes after out-of-hospital cardiac arrest, although most of this evidence is healthcare-wide or device-class specific rather than surgery-specific. Although regulatory and governance responses are strengthening, they remain fragmented. The review highlights secure design engineering, human factors, workforce readiness, specialty-specific threat models, and registries as priorities and draws out what each implies for surgeons, anesthetists, device manufacturers, regulators, and hospital leaders.
Hip fractures are a major cause of morbidity and mortality among older adults and frequently require hospitalization and surgical intervention. Patients with hip fractures are particularly vulnerable to pressure ulcers due to immobility, frailty, and comorbidities. This systematic review evaluated the prevalence of pressure ulcers following hip fracture and examined perioperative factors associated with their development. A systematic review was conducted in accordance with PRISMA guidelines. Ovid MEDLINE, Embase, and Ovid Emcare were searched from inception to May 24, 2025. Studies including patients with hip fractures reporting pressure ulcer outcomes were eligible. Randomized controlled trials, cohort studies, and case series with ≥10 patients were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria and the Joanna Briggs Institute (JBI) critical appraisal checklist. Given anticipated heterogeneity, pressure ulcer prevalence was summarized descriptively using study-level medians, interquartile ranges (IQR), and ranges. Subgroup analyses were performed according to mattress type, nutritional status, surgical procedure, and timing of surgery. Eighty-two studies comprising 63,921 patients were included. The median reported patient age was 81 years. Across all studies, the median pressure ulcer prevalence was 8.0
The American Society of Anesthesiologists (ASA) physical status classification is a cornerstone of perioperative risk management and surgical patient safety. In clinical practice, the initial assessment is frequently documented by surgical teams, leading to interdisciplinary variability. This study evaluated baseline ASA scoring accuracy among practicing surgeons and assessed the immediate impact of a brief, focused educational module on preventing documentation errors. In this prospective, pre-post interventional study conducted at a tertiary academic hospital, 50 practicing surgeons from various specialties evaluated ten validated, borderline clinical case scenarios to establish baseline scoring accuracy. A senior anesthesiologist then delivered a focused, one-hour interactive lecture addressing the updated ASA definitions, subjective boundaries, common pitfalls, and the emergency (“E”) modifier. Immediately following the session, a post-test with randomized scenario orders was administered. Accuracy rates were analyzed using the McNemar and Fisher’s exact tests. The one-hour educational session led to substantial, statistically significant improvements across all categories. Correct classifications for ASA II rose from 67.3
The association between hospital volume and outcomes after gastric cancer resection remains controversial. This Swiss national registry study investigated the association between annual hospital-volume for gastric cancer resection and short-term outcomes. This retrospective population-based study included adult patients undergoing elective gastric cancer resection in Switzerland between 2013 and 2022. Annual hospital volume was defined as the number of gastric cancer resections performed at the treating hospital in the calendar year of surgery. The primary endpoint was in-hospital mortality. Secondary endpoints were postoperative complications, failure to rescue (FTR), reoperation, and length of hospital stay (LOS). Generalized additive regression models (GAM), standardized mortality ratios (SMR), quantile regression, and trend tests were used to assess the association with hospital volume. Among 3,861 gastric cancer resections, in-hospital mortality was 3.1
Polytrauma remains a leading cause of death in individuals younger than 40 years and poses major challenges during early resuscitation and subsequent clinical management. Beyond early mortality from hemorrhage, post-traumatic inflammatory and infectious complications such as systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome (MODS) are of increasing clinical relevance. Leukocyte count is a simple and routinely available laboratory parameter. This systematic review aimed to evaluate whether leukocyte count on admission is associated with post-traumatic complications and mortality. A systematic review in accordance with the PRISMA guidelines was conducted. PubMed/MEDLINE and EMBASE were systematically searched for original English-language clinical studies published between January 1, 2000, and July 31, 2025, that investigated leukocyte counts following adult polytrauma. After deduplication, 2,169 records were independently screened by three investigators based on titles and abstracts. Thirty-two reports were sought for retrieval, and 12 studies were finally included. Disagreements were resolved by consensus. Data on study characteristics, patient and injury characteristics, leukocyte counts and kinetics, and clinical outcomes were extracted and qualitatively synthesized. Study quality and risk of bias were assessed using the Newcastle–Ottawa Scale. A sample-size-weighted mean admission leukocyte count was calculated from the reported study-level means, and associations were analyzed using Spearman’s rank correlation. After subsequent screening 12 studies with overall 15,658 patients were finally included in the current review. Across all studies, leukocyte counts after trauma were elevated compared with reference values. The weighted mean leukocyte count across studies was 10.26 × 10^9/L. The proportion of blunt trauma was positively correlated with mean leukocyte count (rho = 0.775, p = 0.04). Pneumonia and SIRS were reported in three and four studies, respectively. One study reported higher mortality in patients with persistent leukocytosis after trauma. This review demonstrates that leukocyte counts are consistently elevated following trauma. Although some studies suggested associations with morbidity and mortality, the available evidence remains insufficient for firm prognostic conclusions because of substantial heterogeneity and the predominantly retrospective design of the included studies. Further research should focus on leukocyte subpopulations, particularly neutrophils, to improve understanding of post-traumatic immune responses and their clinical relevance.
Guideline reversals and reversals of randomized controlled trial (RCT) treatment effect estimates have been repeatedly documented in critical care syndrome research over several decades. Critical care syndrome RCTs differ structurally from conventional disease-based RCTs. Rather than enrolling patients on the basis of a specific disease or causal mechanism, they typically employ consensus-derived eligibility criteria composed of disease-and cause-agnostic prognostic physiological thresholds, laboratory abnormalities, and/or nonspecific clinical features. These enrollment criteria select a heterogeneous mixture of distinct diseases and causal systems which are mixed into a single trial. Consequently, the resulting treatment-effect estimate is not the average treatment effect of a single disease or causal mechanism. Instead, it represents a second-order average: an overall average generated by averaging disease or causal system-specific average treatment effects across multiple distinct causal systems. The resulting estimate is therefore best understood as an artefactual “mean of causally unrelated means”: a mixture-weighted average of different treatment effects arising from biologically distinct disease processes. The proposed framework implies that the prevalent structure may produce unstable effect estimates and a “cause–mixture paradox,” in which observed treatment effects reverse to the null or opposite sign across trials as the disease mixture of each trial shifts. This framework comprises a new tool for the mathematical assessment of evidentiary strength of critical care trials under guideline consideration.
Formaldehyde is a widely used fixative in medical practice. Accidental introduction into the human body can cause rapid protein coagulation, tissue necrosis, and severe systemic complications. We report the case of a 60-year-old woman who received an inadvertent injection of formaldehyde into the inner lower lip during a minor salivary gland biopsy. The patient developed severe pain, labiomental erythema, and mucosal necrosis. She was initially managed with oral antibiotics, but the development of labiomental cellulitis necessitated hospitalization and intravenous antibiotic therapy, followed by surgical necrosectomy and tissue repair. Postoperative care included pro-healing ointment and bicarbonate mouth rinses, leading to complete recovery. This rare case highlights that medical substance handling requires foolproof institutional safeguards. To prevent this severe complication, clinical facilities must ban the reuse of empty medication vials for chemical storage and enforce a strict dual-signature verification protocol prior to any local anesthetic infiltration.
Modern armed conflicts reveal increasingly complex injury patterns that challenge both civilian and military healthcare systems. In Switzerland, exposure to such injuries is limited. For a planned multicenter, high-fidelity, in-situ simulation-based study assessing trauma care performance across both military and civilian prehospital and clinical teams, a standardized and validated evaluation tool is required. The current study was designed to develop a consensus-based performance assessment tool/framework for evaluating the management of complex combat trauma, integrating civilian and military standards of care. A structured consensus process was conducted, combining an initial nominal group technique with a multi-round Delphi process. Fourteen experts from military medicine, emergency medicine, anesthesiology, and trauma surgery participated. Assessment items were iteratively refined until predefined consensus criteria were achieved. Consensus was reached after five Delphi rounds. The evaluation tool includes 35 items covering key domains such as prioritization of interventions, procedural quality, adherence to trauma principles, and time to critical actions. Initial differences between civilian and military perspectives—particularly regarding cervical spine immobilization, neurological assessment, coagulation management, and fluid resuscitation—were identified and resolved through the consensus process. The results of this Delphi-based evaluation framework highlight both areas of consensus and ongoing controversy in modern combat trauma care. Differences between civilian and military perspectives are largely driven by divergent injury patterns, resources, and operational constraints. By explicitly incorporating these differences into a standardized evaluation tool, this study provides a robust framework for comparing performance across different levels of trauma care.
The increasing adoption of machine learning and artificial intelligence in surgical risk prediction has introduced new challenges related to the fairness and equity of these algorithms. These models range from regression-based risk calculators to machine learning systems, and differential performance may reflect poor calibration within a group, which is mainly a safety concern, or unequal performance between groups, which is mainly an equity concern. Predictive models trained on surgical registry data have shown differential performance across racial and ethnic groups in some studies, raising concerns about the potential for these tools to perpetuate or amplify existing disparities in surgical care. This review examines the sources and mechanisms of algorithmic bias in surgical risk prediction models, evaluates the evidence for differential model performance across patient subgroups, and discusses emerging debiasing strategies and regulatory frameworks. Training datasets from major surgical registries frequently contain incomplete or poorly granular race and ethnicity data, and the inclusion of race as a predictive variable remains controversial. Individual studies have reported lower sensitivity or higher false-negative rates for specific subgroups, potentially leading to an underestimation of surgical risk in those groups, although such discrimination-based measures do not by themselves establish miscalibration or demonstrated harm. Debiasing techniques, including reweighting, adversarial training, and fairness-aware multitask learning, have shown promise but remain largely untested in surgical contexts and are constrained by inherent trade-offs between within-group calibration and error rate parity across groups. Although regulatory bodies have begun to address algorithmic fairness, standardized auditing frameworks for surgical prediction models are still lacking. This review highlights the need for multicenter, demographically diverse validation studies, transparent model reporting, and equity-focused governance to ensure that artificial intelligence in surgery serves all patients safely and equitably. Not applicable.
Abstract Background Although e-bike accidents are of growing clinical relevance, there is limited large-scale research comparing injury patterns and outcomes between e-bike (EB) and conventional bicycle (CB) accidents in large patient cohorts. This study performed comparative analyses of both groups to identify patients at risk and guide future prevention and clinical management strategies. Methods A retrospective analysis of the TraumaRegister DGU® was conducted. Patients aged 16 years or older who sustained severe injuries (AIS ≥ 3 in minimally one body region) in accidents involving conventional bicycles or e-bikes between January 2020 and December 2023 were included. Patient demographics, injury patterns, trauma severity, treatment characteristics, and clinical outcomes were analyzed. Results A total of 9,170 bicycle accident cases were included (EB n = 1,160; CB n = 8,010). EB riders were significantly older than CB riders (median age 63 years; IQR 53-73 vs. 57 years IQR 44-69; p < 0.001) and more frequently sustained polytrauma (16.7% vs. 12.3%; p < 0.001). Compared with CB riders, EB riders more often suffered injuries to the head (67.2% vs. 56.2%; p < 0.01), face (22.7% vs. 17.8%; p < 0.001), and chest (55.2% vs. 51.8%; p = 0.030), and were more likely to sustain injuries affecting multiple body regions (p < 0.001). Primary ICU treatment was required more frequently after EB accidents (70.3% vs. 63.5%; p < 0.001). Age-stratified analyses showed that younger EB riders were more frequently involved in nighttime and alcohol-related accidents, whereas mortality increased significantly with age, from 2.7% in patients aged 16-59 years to 18.6% in those aged ≥ 80 years. Conclusions E-bike accidents are associated with a higher prevalence of head, face, and chest injuries, increased rates of polytrauma and multi-region injuries, and a greater need for ICU treatment compared with conventional bicycle accidents. These differences are particularly relevant in older riders, who represent the majority of severely injured e-bike users and experience substantially higher mortality rates. Targeted prevention strategies, improved protective measures, and age-specific risk communication may help reduce the burden of e-bike-related injuries.
Perioperative burn or pressure–thermal skin injury is a rare but preventable complication of surgery. Although burns related to warming devices or electrosurgical instruments have been reported, such injuries following arthroscopic anterior cruciate ligament (ACL) reconstruction are exceedingly uncommon. We report an unrecognized perioperative deep partial-thickness skin injury involving the dorsum of the foot, most consistent with a thermal or combined pressure–thermal injury, following revision arthroscopic ACL reconstruction under general anesthesia. A pneumatic tourniquet was applied for 120 min. A forced-air warming system was used for upper-body warming without direct contact with the operative limb, which was loosely covered with a stockinette without additional padding. Shortly after transfer from the post-anesthesia care unit to the ward, a 8 × 4 cm deep partial-thickness skin injury was identified on the ipsilateral dorsum of the foot. Conservative wound care was initiated, and the lesion gradually epithelialized over approximately three months. The injury resulted in transient soft-tissue contracture with plantar flexion restricted to approximately 30°, interfering with early postoperative rehabilitation. At 9 months after surgery, the wound had fully healed, ankle range of motion had recovered to 15° of dorsiflexion and 40° of plantar flexion, and the patient reported no resting pain, shoe-wear difficulty, or limitation in daily activities. Clinically significant perioperative deep partial-thickness skin injury can occur during routine knee arthroscopy even in the absence of an obvious direct thermal source. This case suggests that local pressure, drape-related insulation, impaired distal heat dissipation due to tourniquet use, and retained ambient heat may interact to produce occult injury. This case highlights system-level prevention opportunities, including distal extremity padding, avoidance of heat trapping under drapes, and routine whole-limb skin inspection in the post-anesthesia care unit and after ward transfer to facilitate early recognition of occult injuries.
Surgical patient safety remains a major challenge in resource-limited settings, where preventable harm may be increased by delayed assessment, limited monitoring, workforce shortages, weak documentation, and inconsistent use of standardized perioperative protocols. Enhanced Recovery After Surgery offers an evidence-based pathway for improving perioperative care, while artificial intelligence may support risk prediction, complication surveillance, audit feedback, and clinical decision-making. This correspondence argues that artificial intelligence and Enhanced Recovery After Surgery should be considered complementary patient safety strategies rather than separate innovations. In low-resource surgical systems, their combined use may strengthen perioperative reliability, improve early recognition of risk, and support continuous quality improvement. However, implementation must be gradual, locally adapted, ethically governed, and built on essential safety practices such as checklist adherence, multidisciplinary teamwork, staff training, and audit.
Abstract Background Venous thromboembolism (VTE) is a major cause of morbidity among surgical patients. Patient Safety Indicator 12 (PSI-12) identifies perioperative VTE events. This study evaluates whether early admission duplex ultrasound identifies VTEs associated with PSI-12 coding and assesses PSI-12 classification accuracy. Methods A single-center retrospective analysis was conducted on surgical patients with a venous duplex ultrasound within 48 h of admission at a large academic medical center (2013–2024). Two cohorts were analyzed: (1) all surgical patients with early duplex imaging, (2) PSI-12 positive elective surgical patients with early duplex imaging. The primary outcome was the prevalence of pre-existing DVT identified within 48 h among PSI-12 positive patients. Diagnostic accuracy of early abnormal duplex findings for predicting PSI-12 classification was assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results Among all 10,498 surgical patients, 10.6% had positive duplex findings for DVT. PSI-12 positive patients had double the prevalence compared to PSI-12 negatives (20.9% vs. 10.4%, p < 0.001). In PSI-12 positive elective cases, 10.7% of preoperative duplex studies identified a DVT. Misclassification, defined as PSI-12 positive admissions without imaging-confirmed DVT or pulmonary embolism, occurred in 8.7% of elective cases. Overall, 36.7% of PSI-12 positive patients had abnormal early duplex findings. Early duplex demonstrated limited sensitivity but high specificity (sensitivity 36.7%, specificity 81.7%, PPV 3.7%, NPV 98.5%). Conclusions Our findings suggest possible pre-existing disease rather than hospital-acquired VTE in PSI-12 positive patients. Incorporating admission duplex studies could improve PSI-12 classification accuracy, reduce costs, and enhance patient safety.
BACKGROUND:Hydatid disease (HD) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus granulosus. The liver is primary affected, accounting for up to 70% of cases, but it can also affect other organs such as the spleen, pelvic cavity, and bones. Patients can remain asymptomatic for 10 to 15 years. This report, accompanied by an extensive literature review, aims to contribute to the understanding of the diagnostic and surgical management of giant hepatic hydatid cysts, given their rarity and the variety of locations in the body where they occur. CASE PRESENTATION:A 32-year-old male presented with a 3-day history of diffuse abdominal pain. Examination revealed a tense abdomen, and laboratory tests showed mild leukocytosis. Ultrasound and CT scan demonstrated two giant hepatic hydatid cysts. The patient underwent elective open surgery with aspiration of both cysts, instillation of a scolicidal solution, removal of the germinative membranes, and partial pericystectomy with preservation of hepatic tissue. A drain was placed, and the postoperative course was uneventful. He was discharged after 3 days of hospitalization. Albendazole therapy was initiated 2 weeks postoperatively and continued for 6 months. At 6-month follow-up, the patient was asymptomatic with normal liver function tests and no evidence of recurrence on imaging. CONCLUSION:Our case highlights that despite the limited medical resources in conflict-affected Syria, hepatic hydatid cysts can be successfully managed effectively through a combination of radiological evaluation, open surgical intervention, and antiparasitic drug therapy, resulting in a significant improvement in patient outcomes. CLINICAL TRIAL NUMBER:Not applicable.
BACKGROUND:Abdominal splenosis is a benign condition that occurs when splenic tissue is implanted within the abdominal cavity after splenic trauma or splenectomy. Most patients remain asymptomatic, and the condition is often detected incidentally. However, when multiple nodules are present, they can closely resemble peritoneal metastases and create uncertainty, particularly when they are encountered unexpectedly during surgery. A lack of awareness may lead to overly aggressive surgical decisions or delays in definitive management. CASE PRESENTATION:We describe a patient in whom abdominal splenosis was incidentally identified during the repair of an incisional hernia associated with a chronic discharging sinus. During exploration, numerous reddish-brown nodules were noted over the omentum and peritoneal surfaces, raising concern for peritoneal carcinomatosis, especially given the patient's family history of colorectal cancer. A few representative nodules were excised and sent for histopathological examination. Intraoperative frozen section analysis was not performed, and therefore, the decision to proceed was based on gross intraoperative findings. In the absence of frozen-section confirmation, the decision to proceed with mesh repair was made based on the benign intraoperative appearance of the nodules (well-circumscribed, non-infiltrative, no ascites), and a clean operative field without evidence of infection. Considering these findings, the surgical team proceeded with definitive mesh repair of the hernia during the same operation. Histopathology later confirmed the presence of splenic tissue consistent with splenosis. The patient had an uneventful postoperative recovery. CONCLUSION:This case demonstrates that intraoperative recognition of splenosis, supported by careful assessment and limited biopsy, allows safe continuation of planned surgery without unnecessary delay or overtreatment. Awareness of this entity is essential to guide appropriate intraoperative decision-making and avoid misinterpretation as metastatic disease.
Hip fractures in older adults are associated with high morbidity, mortality, and healthcare costs. Their incidence is rising with population aging, yet Brazil still lacks a unified national registry to systematically monitor these cases. We developed a consensus-based registry protocol based on a review of national and international literature on hip fracture registries, in conjunction with alignment to the Fragility Fracture Network Minimum Common Dataset (MCD), and multidisciplinary expert consensus, adapted to the Brazilian healthcare context. The main outcome of this work is the development of a structured national hip fracture registry protocol for older adults in Brazil. Based on literature review, international registry models, and expert consensus, a standardized and tiered dataset aligned with the Fragility Fracture Network Minimum Common Dataset was developed, together with operational definitions of key variables and indicators and a national governance and implementation framework. The unified dataset presented in the HFR-Brazil – Minimum Common Dataset (FFN-aligned) – Unified Table constitutes the main outcome of this study. Implementing a national hip-fracture registry in Brazil is a strategic priority to improve orthogeriatric care, reduce morbidity and mortality, and align national practices with international standards. The protocol provides a pragmatic, evidence-based roadmap for nationwide adoption and for future publications reporting objective outcomes once data collection begins.
Adverse events following elective cosmetic surgery can raise concerns about patient safety, particularly in facilities with variable oversight of infection‑prevention practices. Severe early‑onset postoperative infections caused by multidrug‑resistant organisms may indicate system‑level failures in sterile processing or infection control protocols. We report a rapidly progressing polymicrobial multidrug‑resistant surgical site infection in a previously healthy woman seven days after elective abdominoplasty with liposuction and lipofilling. The patient experienced early clinical deterioration requiring multiple emergency debridements, intensive care admission, prolonged antimicrobial therapy, negative‑pressure wound management, and eventual skin grafting. Microbiology revealed evolving multidrug‑resistant Pseudomonas aeruginosa, ESBL‑producing Enterobacterales, Staphylococcus epidermidis, and Klebsiella species. The severity, early onset, and unusual microbiological profile raised concerns for a possible sterilization or infection‑control breach at the original surgical facility. Early severe postoperative infections following elective procedures may signal underlying system failures rather than isolated clinical complications. Strengthening sterile processing oversight, improving infection‑control auditing, and ensuring timely escalation of care are critical to preventing similar events and safeguarding patient safety.
