The research, published in BMC Health Services Research, examined a question that has long frustrated implementation scientists: how well do urology nurses translate their knowledge of ERAS principles into the actual care of patients recovering from surgery for benign prostatic hyperplasia, or BPH? BPH, a non-cancerous enlargement of the prostate gland, is one of the most common conditions affecting aging men, and surgical treatment—whether transurethral resection, laser enucleation, or open prostatectomy—remains a mainstay when medications fail. Because these patients often recover quickly, the quality of perioperative nursing care can make an outsized difference in their experience and outcomes.

Between January and May 2026, a team led by Xuefei Liang of Yangjiang Hospital of Traditional Chinese Medicine surveyed 106 registered urology nurses working across seven wards in five hospitals in Yangjiang, a city in Guangdong province in southern China. The multicenter cross-sectional design allowed the researchers to capture a snapshot of ERAS knowledge and self-reported practice across a range of institutional settings, from larger hospitals to smaller district facilities. Each nurse completed validated instruments measuring their ERAS knowledge, their self-reported ERAS practice, and—crucially—their capacity to translate knowledge into action, a construct the researchers treated as distinct from knowledge itself.

The headline finding was deceptively reassuring: on average, the nurses’ overall practice scores actually exceeded their knowledge scores, with practice at 71.8 percent and knowledge at 68.7 percent, a mean gap of just 3.1 percentage points. In other words, these nurses were not simply failing to apply what they knew. But when the researchers dissected the data by individual ERAS domains, a striking exception emerged. Perioperative thermal management—keeping patients warm before, during, and after surgery—showed the largest knowledge-to-practice gap of any domain, at 13.4 percentage points. Nurses knew that maintaining normothermia reduces complications, yet they reported doing it far less consistently than their knowledge would predict.

That gap matters more than it might sound. Perioperative hypothermia is a well-established driver of surgical complications: even mild drops in core body temperature can impair blood clotting, increase the risk of surgical site infection, trigger cardiac events, and prolong recovery by forcing the body to spend energy rewarming. For BPH patients, many of whom are older and may have diminished thermoregulatory capacity, the stakes are real. Operating rooms are kept cool for the comfort of surgical teams, irrigation fluids used during prostate surgery can cool the body from within, and general or spinal anesthesia blunts the shivering response that normally defends core temperature. Thermal care is one of the cheapest and simplest ERAS elements to deliver—warm blankets, fluid warmers, forced-air warming devices—yet it is precisely the element slipping through the cracks.

To understand what actually drives ERAS practice, the researchers built a multivariable linear regression model. The outcome was the total self-reported ERAS practice score, and the candidate predictors included hospital level, formal ERAS training, monthly BPH surgical volume, ERAS knowledge score, and knowledge-to-practice translation capacity. Three factors emerged as independently associated with better practice. Hospital level carried a regression coefficient of 9.02 (95 percent confidence interval, 4.72 to 13.32), meaning nurses at higher-level hospitals reported substantially better ERAS practice than their peers elsewhere. Knowledge score was independently associated with practice at B = 1.63 (95 percent CI, 0.79 to 2.47), and translation capacity—the ability to convert what one knows into what one does—was the strongest single predictor, at B = 10.38 (95 percent CI, 5.33 to 15.42).

Perhaps the most provocative result was what did not matter. Formal ERAS training showed no independent association with practice, with a coefficient of −1.59 (95 percent CI, −6.12 to 2.95), a range that comfortably includes zero. This finding cuts against the intuitive assumption that sending nurses to training courses will automatically change bedside behavior. The study’s authors concluded that ERAS nursing practice is not determined by knowledge or training alone, and that organizational context and the ability to translate knowledge into action may be more important targets for strengthening ERAS implementation in BPH surgery. In plain terms: a certificate on the wall does not guarantee a warm blanket on the bed.

The hospital-level effect offers a clue about why. Higher-level hospitals typically command greater resources—more staff per patient, better equipment such as forced-air warming units and fluid warmers, established quality-improvement infrastructure, and institutional cultures in which protocol adherence is monitored and rewarded. A nurse in a well-resourced tertiary ward may want to deliver evidence-based thermal care and simply be able to, while a nurse in a smaller district hospital may face staffing shortages, missing equipment, or workflow pressures that make the same care impractical. This is the classic terrain of implementation science: behavior change in healthcare is rarely a simple function of education, because clinicians operate within systems that either enable or obstruct good practice.

The study’s emphasis on knowledge-to-practice translation capacity as the strongest predictor is especially noteworthy. This construct captures something beyond textbook knowledge—the practical judgment, confidence, autonomy, and environmental support that allow a nurse to act on what they know in the moment a patient needs it. Interventions designed around this insight look different from traditional continuing education. They might include bedside decision-support tools, protocol checklists embedded into electronic records, peer champions who model ERAS behaviors on the ward, audit-and-feedback cycles that show nurses how their unit’s practice compares with benchmarks, and organizational commitments to supplying the equipment that protocols assume. The finding that training alone was not associated with practice suggests that such system-level supports, rather than more lectures, may be where investment pays off.

There are limits worth keeping in mind. The study was cross-sectional, capturing a single moment in time, so it can identify associations but cannot prove that translation capacity causes better practice—though the biological and organizational plausibility is strong. The sample of 106 nurses from five hospitals in a single Chinese city, while multicenter, may not generalize to other regions or health systems. And because practice was self-reported, social desirability bias could inflate scores; nurses may report delivering care they believe they should deliver. Still, the consistency of the pattern—practice broadly tracking knowledge except where systems fail, with organizational level and translation capacity dominating the statistical model—gives the findings weight.

For the millions of men worldwide who undergo prostate surgery each year, the practical message is encouraging in an unexpected way. The barrier to better recovery care is not primarily a knowledge deficit among nurses, which would demand years of curriculum reform. It is a delivery problem, and delivery problems can be fixed faster. Hospitals that invest in warming equipment, streamline ERAS protocols into daily workflow, and empower nurses to act on their training could close the thermal management gap quickly. As ERAS continues to expand across surgical specialties, this study from Yangjiang is a reminder that the last mile of evidence-based medicine is walked not by guidelines but by nurses at the bedside—and that health systems must equip them for the walk.

Subject of Research: The gap between ERAS knowledge and nursing practice in postoperative care of benign prostatic hyperplasia patients

Article Title: Gap between ERAS knowledge and practice among urology nurses caring for postoperative benign prostatic hyperplasia patients: a cross-sectional study

Article References: Liang, X., Gao, X., Liang, P., Xiao, R., Zhang, N., Tan, M., Huang, R., Wu, P., & Li, X. (2026). Gap between ERAS knowledge and practice among urology nurses caring for postoperative benign prostatic hyperplasia patients: a cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15672-y

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15672-y

Keywords: ERAS, enhanced recovery after surgery, urology nursing, benign prostatic hyperplasia, knowledge-practice gap, perioperative thermal management, postoperative care, cross-sectional study, nursing education, implementation science, hospital level, China

ERAS pathways are not a single intervention but a coordinated bundle of evidence-based practices that touch every phase of the surgical journey. They typically include thorough pre-operative counseling about recovery milestones, a preference for minimally invasive surgical techniques, avoidance of routine nasogastric tubes, multimodal pain control built around intravenous nonsteroidal anti-inflammatory drugs and acetaminophen rather than opioids alone, early removal of urinary catheters, early mobilization out of bed, rapid advancement of oral intake, and clearly defined discharge targets. The concept, first popularized in colorectal surgery, rests on a simple physiological insight: the traditional rituals of post-operative care, such as prolonged bed rest, bowel rest, and drainage tubes, often do more harm than good, delaying the return of normal gut function and prolonging hospitalization.

Despite widespread adoption in colon and rectal surgery, ERAS programs for gastrectomy have lagged behind, and prospective evaluations in diverse American patient populations have been scarce. Most of the existing evidence comes from European and Asian centers, where gastric cancer surgery is performed at higher volumes and patient demographics differ considerably. The new study was designed to fill that gap. The investigators registered their trial at ClinicalTrials.gov in August 2018 and prospectively enrolled patients undergoing distal subtotal or total gastrectomy with either prophylactic or curative intent at City of Hope National Medical Center in Duarte, California. Of 78 patients with gastric cancer screened, 51 were enrolled and received structured pre-operative counseling on each element of the ERAS pathway before their operations.

The surgical mix reflected modern practice at a high-volume cancer center. Roughly 41 percent of enrolled patients underwent distal subtotal gastrectomy, in which the distal portion of the stomach is removed, while 59 percent underwent total gastrectomy, a more extensive operation requiring reconstruction of the digestive tract. A striking 80 percent of the procedures were performed robotically, with the remaining 20 percent done through an open approach. This heavy reliance on minimally invasive technique is itself one of the eight ERAS elements the team tracked, reflecting evidence that smaller incisions and less tissue trauma translate into faster recovery of bowel function and less post-operative pain.

The eight elements selected for the pathway were deliberately concrete and measurable. They included a pre-operative discussion about recovery milestones, a preference for minimally invasive surgery, avoidance of nasogastric tubes, post-operative intravenous NSAIDs or acetaminophen, early removal of the urinary catheter, early mobilization, early diet advancement, and a defined post-operative discharge day. The primary endpoint was discharge by post-operative day five for distal subtotal gastrectomy patients and by post-operative day six for total gastrectomy patients. Secondary endpoints included patient-reported quality of life, measured with validated European Organisation for Research and Treatment of Cancer quality of life questionnaires, and the reasons for any deviations from the pathway.

The results were encouraging. Median length of stay was 4.5 days for distal subtotal gastrectomy patients and 5.4 days for total gastrectomy patients, figures that compare favorably with historical norms for these operations. Among patients discharged at least 24 hours after their target discharge date, 86 percent of distal subtotal gastrectomy patients, 18 of 21, had adhered to the ERAS elements, compared with 71 percent of total gastrectomy patients, 22 of 31. Notably, every patient in the study was discharged directly home rather than to a rehabilitation facility or skilled nursing unit, an outcome that underscores the functional recovery the pathway is designed to promote.

The clearest signal in the data concerned complications. Twelve of the 51 patients, or 24 percent, experienced post-operative complications, and these patients had significantly lower adherence to the ERAS elements. Among patients with complications, 81 percent experienced delays in discharge, a relationship that was highly statistically significant. This finding cuts in two directions. On one hand, it suggests that complications remain the dominant force pushing patients off the pathway and keeping them in the hospital. On the other hand, it reinforces the value of adherence itself: patients who could follow the pathway largely did go home on schedule, and deviations clustered around clinical setbacks rather than arbitrary failures of the protocol.

Perhaps the most patient-centered finding came from the quality of life analysis. Global quality of life scores were preserved six months after gastrectomy, indicating that patients overall sense of well-being returned to pre-operative levels. Sub-categories told a more nuanced story. Physical functioning, fatigue, and pain all initially declined in the early post-operative period, as any patient who has undergone major abdominal surgery would expect, but these domains recovered by six months after the operation. For a procedure as invasive as total gastrectomy, demonstrating that patient-reported well-being rebounds to baseline within half a year is a meaningful benchmark, and it provides surgeons and patients alike with concrete expectations for the recovery arc.

The study population was also notable for its ethnic diversity, an important consideration given that gastric cancer incidence and outcomes vary substantially across racial and ethnic groups in the United States. The investigators argue that their findings demonstrate the feasibility of delivering a standardized, procedure-specific ERAS pathway in an ethnically diverse U.S. population, achieving high adherence to discharge targets while preserving quality of life. They caution, however, that this was a single-center prospective trial, and they call for prospective multicenter validation of complete ERAS programs to confirm the results more broadly.

For the surgical oncology community, the trial adds a missing piece of evidence. Randomized controlled trials comparing full ERAS bundles against conventional care are difficult to run, because the components of these pathways are individually well supported and withholding them raises ethical concerns. Prospective adherence studies like this one, which enroll patients, counsel them on the pathway in advance, track compliance with each element, and link adherence to hard outcomes such as length of stay, complications, and quality of life, offer a practical alternative. The message from this trial is that when a cancer center commits to the full bundle, from pre-operative education to early feeding and mobilization, stomach cancer patients can expect to be home in under a week and feeling like themselves again within months. As ERAS programs continue to spread through surgical oncology, studies of this kind provide the roadmap for implementing them well, and the benchmarks against which future programs should be judged.

Subject of Research: Adherence to an enhanced recovery after surgery pathway following gastrectomy for gastric cancer, with surgical outcomes and quality-of-life endpoints

Article Title: Prospective evaluation of adherence to an enhanced recovery pathway after gastrectomy at a U.S. comprehensive cancer center: surgical outcomes and quality-of-life endpoints

Article References: Prospective evaluation of adherence to an enhanced recovery pathway after gastrectomy at a U.S. comprehensive cancer center: surgical outcomes and quality-of-life endpoints. (n.d.). https://doi.org/10.1186/s12885-026-17097-6

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17097-6

Keywords: ERAS, gastrectomy, gastric cancer, enhanced recovery after surgery, quality of life, minimally invasive surgery, robotic surgery, length of stay, surgical oncology, post-operative care, prospective trial, BMC Cancer

The research team, working at the Laboratory Animal Center of Shanghai University of Traditional Chinese Medicine, set out to answer two linked questions. First, could they establish a stable and reproducible rat model of lung injury driven by myocardial ischemia and reperfusion? Second, could pretreatment with electroacupuncture reduce that injury, and if so, did the HMGB1/RAGE pathway, a pair of molecules long implicated in acute lung inflammation, sit at the center of the mechanism? Their answer to both questions, based on a series of five carefully controlled experiments in male Sprague-Dawley rats, was yes.

Building the model required calibrating the injury. The researchers ligated the left anterior descending coronary artery in anesthetized rats for 30 minutes, 45 minutes, or one hour, then released the snare to allow 24 hours of reperfusion, confirming ischemia by visible cyanosis of the ventricular wall and ST-segment elevation on the electrocardiogram. Only the one-hour ischemia protocol produced consistent, measurable lung damage. In those animals, arterial oxygen partial pressure and the oxygenation index fell significantly, the alveolar-arterial oxygen gradient rose, and the lung wet-to-dry weight ratio, a standard gauge of pulmonary edema, climbed sharply. Under the microscope, the lungs showed alveolar collapse, hemorrhage, thickened septa, and dense inflammatory infiltration, and immunostaining revealed abundant cleaved caspase-3, a hallmark of apoptosis. Shorter ischemic periods produced weaker or statistically insignificant changes, establishing one hour of ischemia followed by 24 hours of reperfusion as the reliable model.

With the model in hand, the team turned to electroacupuncture. They stimulated two classical acupoints, Zusanli (ST36) on the hind limb and Feishu (BL13) on the back near the lungs, using a 2/20 Hz dense-disperse waveform for 30 minutes per session. The critical variable was timing. A single 30-minute session immediately before ischemia did essentially nothing: blood gas values, edema measures, injury scores, and apoptotic cell counts in that group were indistinguishable from the untreated ischemia-reperfusion group. But when the same stimulation was repeated over three consecutive days before the procedure, the picture changed dramatically. Oxygenation improved, the wet-to-dry ratio dropped, lung injury scores fell, and cleaved caspase-3 staining diminished significantly compared with injured animals that received no pretreatment.

The protective effect was accompanied by a clear anti-inflammatory signature. Quantitative PCR showed that ischemia-reperfusion drove up the messenger RNA of the pro-inflammatory cytokines IL-1β and IL-6 and the chemokines CXCL1 and CXCL2 in lung tissue. Three days of electroacupuncture pretreatment significantly reduced all four transcripts at four hours of reperfusion, with IL-6 and CXCL1 still suppressed at 24 hours. Immunohistochemistry told a parallel story at the cellular level: myeloperoxidase-positive neutrophils and F4/80-positive macrophages, the two dominant infiltrating populations, flooded the injured lungs after reperfusion but were markedly fewer in the pretreated animals at both early and late time points.

The molecular centerpiece of the study was HMGB1, a nuclear non-histone protein that escapes from stressed cells and acts as a danger signal when it binds transmembrane receptors, most notably RAGE and the Toll-like receptors. Western blotting and PCR revealed that ischemia-reperfusion significantly increased both HMGB1 and RAGE in lung tissue, and electroacupuncture pretreatment brought both back down at four and 24 hours of reperfusion. Because HMGB1 is known to recruit and activate inflammatory cells in many forms of acute lung injury, the authors reasoned that this axis could be the plausible bridge between the systemic inflammatory surge triggered by cardiac ischemia and the pulmonary damage that follows.

A key question was where the lung HMGB1 actually came from. The injured heart itself is an obvious suspect. Yet when the researchers measured HMGB1 expression in heart tissue, they found it elevated only in the earliest phase of inflammation and essentially normal by 24 hours of reperfusion, precisely when lung HMGB1 remained high. Moreover, electroacupuncture reduced lung HMGB1 without changing myocardial infarct size, measured by triphenyltetrazolium chloride staining, indicating that the treatment was not simply shrinking the cardiac wound and thereby sending fewer danger signals. The accumulating HMGB1 in the lungs, the data suggested, was generated locally rather than imported from the heart.

To test causality more directly, the team delivered recombinant HMGB1 protein directly into the lungs via intubation-mediated intratracheal administration before reperfusion. Adding the protein to injured animals worsened respiratory dysfunction, edema, and histological injury to some degree. More tellingly, in rats that had received the three-day electroacupuncture pretreatment, intratracheal recombinant HMGB1 significantly raised lung HMGB1 and RAGE expression, lowered oxygenation indices, increased the wet-to-dry ratio, worsened injury scores, and boosted apoptotic cell counts. In other words, flooding the lungs with the very molecule the therapy suppresses partially reversed its benefits, evidence that HMGB1 is not merely a bystander but a functional target of the electroacupuncture effect.

The authors are candid about the limits of their work. The validation relied on recombinant protein challenge rather than genetic knockout, which leaves some causal uncertainty, and the sample sizes were small, with five rats per group. All experiments were conducted in male animals, and no clinical data exist yet to confirm that the findings translate to patients awaiting cardiac surgery. Larger, multicenter human studies will be needed before electroacupuncture pretreatment can be recommended as a standard element of perioperative lung protection.

Even so, the study adds a compelling piece to a growing body of evidence that neuromodulation through acupuncture-like stimulation can precondition distant organs against surgical stress. Previous work has shown electroacupuncture protecting the lungs during cardiopulmonary bypass by dampening inflammasome activation and oxidative stress pathways, and the new findings extend that logic to the specific HMGB1/RAGE axis in the setting of myocardial ischemia and reperfusion. If the mechanism holds in humans, a low-side-effect intervention delivered in the days before surgery could help reduce the burden of postoperative pulmonary complications, aligning with the principles of enhanced recovery after surgery and broadening the toolkit of perioperative organ protection.

Subject of Research: Electroacupuncture pretreatment and protection against myocardial ischemia/reperfusion-induced lung injury via the HMGB1/RAGE pathway in rats

Article Title: Electroacupuncture pretreatment alleviates myocardial ischemia/reperfusion‐induced lung injury by inhibiting the expression of HMGB1/RAGE in male rats

Article References: Xie, C., Zhang, J., Zhang, Y., Chi, H., Yong, Y., & Song, J. (2026). Electroacupuncture pretreatment alleviates myocardial ischemia/reperfusion‐induced lung injury by inhibiting the expression of HMGB1 / RAGE in male rats. Physiological Reports, 14(18), Article e71066. https://doi.org/10.14814/phy2.71066

Image Credits: AI Generated

DOI: 10.14814/phy2.71066

Keywords: electroacupuncture, myocardial ischemia-reperfusion, lung injury, HMGB1, RAGE, inflammation, acute lung injury, cardiac surgery, pulmonary complications, rat model, preconditioning, enhanced recovery after surgery