The study included 126 patients with muscle-invasive bladder cancer who underwent radical cystectomy with a Bricker ileal conduit, a urinary diversion technique in which a segment of intestine is used to create a stoma. Sixty-three patients were managed with a 22-element ERAS protocol adapted from ERAS Society guidelines, while 63 historical controls received standard perioperative care. The ERAS pathway combined eight preoperative elements, including patient education, nutritional optimization, carbohydrate loading, and shortened fasting, with seven intraoperative measures such as epidural analgesia, goal-directed fluid therapy, and active maintenance of body temperature, and seven postoperative elements including early feeding, early mobilization, and milestone-based discharge criteria. Many of these components were delivered or coordinated by nursing staff, making the protocol as much a nursing intervention as a surgical one.

To track immune changes, the team drew blood at three standardized timepoints: 24 hours before surgery, 24 hours after surgery, and on postoperative day seven or at discharge. Multiplex flow cytometry quantified cytotoxic CD8-positive T cells, regulatory T cells, and natural killer cells, while a 37-analyte Luminex panel measured inflammatory cytokines and ELISA assays captured soluble immune checkpoint molecules such as soluble PD-L1. The differences between the two groups were striking. In the ERAS cohort, CD8-positive T-cell counts fell by 22.8 percent from baseline in the first 24 hours after surgery, compared with a 41.6 percent decline in the conventional group, a difference that was highly statistically significant. Serum interleukin-6, a key inflammatory cytokine released during surgical stress, averaged 43.2 picograms per milliliter in ERAS patients versus 87.4 picograms per milliliter in conventional patients.

Beyond the cellular counts, the soluble immune landscape also differed. ERAS patients showed lower concentrations of soluble PD-L1 and soluble TIM-3, molecules shed into the bloodstream that are thought to dampen antitumor immunity, and higher levels of interferon-gamma, a cytokine central to cytotoxic immune defense. Natural killer cell activity was also better preserved, at 42.3 percent versus 31.7 percent. By postoperative day seven, several of these measures remained more favorable in the ERAS group, including higher CD8 counts and lower proportions of immunosuppressive regulatory T cells. The authors are careful to note, however, that these timepoint comparisons alone cannot establish a causal effect of ERAS on immune trajectories, since no formal group-by-time mixed-effects analysis was performed.

One of the most intriguing findings is an exploratory four-marker immune index measured 24 hours after surgery, combining CD8-positive T-cell count, interleukin-6, soluble PD-L1, and natural killer cell activity. When the researchers tested this composite score against the risk of infectious complications within 30 days of surgery, it achieved an area under the receiver operating characteristic curve of 0.84, with a 95 percent confidence interval of 0.76 to 0.92. That performance substantially exceeded a reference model based only on ASA score and clinical stage, which reached an AUC of 0.61. Individual markers performed less well, with interleukin-6 alone at 0.76 and CD8 count alone at 0.73, suggesting that the integration of multiple immune dimensions carries the predictive signal.

The team also examined the tumors themselves. Using multiplex immunofluorescence on surgical specimens, they quantified immune cell infiltration in tumor nests, invasive margins, and surrounding stroma. Specimens from the ERAS cohort showed higher densities of CD8-positive tumor-infiltrating lymphocytes in both tumor nests and invasive margins, lower densities of CD68-positive CD163-positive M2-polarized macrophages, and higher ratios of CD8-positive to FoxP3-positive cells, a measure that weighs cytotoxic against regulatory immune activity. Spatial transcriptomics performed on 24 specimens revealed higher expression of cytotoxic effector genes such as GZMB, PRF1, and IFNG, and lower expression of exhaustion markers including TIGIT, LAG3, and PDCD1 in the ERAS group. The immune-inflamed tumor phenotype, characterized by T cells penetrating deep into tumor tissue, was present in 52.4 percent of ERAS specimens versus 28.6 percent of conventional ones.

Here the authors issue an important caution. Because tumor tissue was collected at the time of cystectomy, before any postoperative ERAS component such as early feeding or mobilization could have taken effect, the tumor immune differences are cross-sectional observations rather than evidence that ERAS remodels the tumor microenvironment. They may reflect pre-existing tumor biology, differences in surgical approach, calendar-period effects, or other confounders. Indeed, the ERAS group had shorter operative times, less blood loss, lower transfusion rates, and more frequent minimally invasive surgery, all of which could independently influence both systemic immunity and tumor immune features.

Clinically, the ERAS group fared better on nearly every recovery measure. Time to first flatus was 2.1 days versus 3.4 days, first oral intake occurred at 8.2 hours versus 28.7 hours, and first mobilization at 12.4 hours versus 24.6 hours. Postoperative length of stay averaged 4.8 days compared with 7.2 days, resting pain scores on the first day after surgery were 3.2 versus 5.1 on a ten-point scale, and total hospitalization costs were 22.4 percent lower. The overall rate of 30-day infectious complications was numerically lower in the ERAS group at 19.0 percent versus 33.3 percent, but this difference did not reach conventional statistical significance after recalculation, with a P value of 0.068.

Survival analyses, while exploratory, added another layer. Among patients with available follow-up, descriptive three-year overall survival proportions were 78.1 percent in the ERAS cohort and 68.3 percent in the conventional cohort, though the authors stress these are not formal Kaplan-Meier estimates for the full cohort. In multivariable Cox models, ERAS management was associated with an overall survival hazard ratio of 0.58, and an eight-gene immune signature comprising cytotoxic effectors, exhaustion markers, FOXP3, CD163, and IL6 showed an even stronger association at a hazard ratio of 0.47. Notably, the survival benefit associated with ERAS appeared concentrated in patients whose tumors had high tumor mutational burden, with a hazard ratio of 0.41 in that subgroup and a nominal interaction P value of 0.048.

The authors are unequivocal that these biomarker and survival findings are hypothesis-generating rather than validated. The four-marker index and eight-gene signature were developed and tested in the same retrospective cohort, creating a real risk of overfitting, and only 33 infectious events were available for the predictive analysis. The single-center historical-control design means ERAS exposure is tightly correlated with calendar period, and secular improvements in surgical technique, infection control, and systemic therapy could account for some of the observed differences. Mean follow-up was approximately 24 months, limiting interpretation of three-year outcomes. What the study does establish is a detailed immunological portrait of what happens to the immune system after major cancer surgery under two different care philosophies, and a roadmap for the prospective, contemporaneous trials with longitudinal immune sampling and paired tumor biopsies that will be needed before any of these signals can guide clinical practice.

Subject of Research: Perioperative immunogenomic differences between ERAS-based and conventional nursing care in muscle-invasive bladder cancer patients undergoing radical cystectomy

Article Title: Perioperative immunogenomics and clinical outcomes under ERAS-based nursing care in muscle-invasive bladder cancer

Article References: Xin, L.-L., Guo, J.-J., Zheng, X.-Y., & Li, Z.-Y. (2026). Perioperative immunogenomics and clinical outcomes under ERAS-based nursing care in muscle-invasive bladder cancer. Frontiers in Genetics, 17, Article 1967034. https://doi.org/10.3389/fgene.2026.1967034

Image Credits: AI Generated

DOI: 10.3389/fgene.2026.1967034

Keywords: bladder cancer, ERAS, radical cystectomy, perioperative immunogenomics, CD8 T cells, tumor immune microenvironment, immune biomarkers, interleukin-6, tumor mutational burden, spatial transcriptomics, nursing care, infectious complications

Dermatology has long occupied a peculiar position in American graduate medical education. It is consistently among the most competitive specialties in the National Resident Matching Program, the algorithm-driven process that pairs applicants with training positions. The combination of a limited number of residency slots, desirable lifestyle characteristics, and strong career prospects means that the ratio of applicants to positions is among the highest in medicine. For students, that competition translates into anxiety, and anxiety, in turn, translates into strategy. One of the most visible strategies is the dual application: submitting materials not only to dermatology programs but also to a second specialty, typically one perceived as less competitive, as a hedge against the possibility of not matching.

The technical foundation of the new analysis is the ERAS specialty dashboard, a publicly accessible data product maintained by the Association of American Medical Colleges. The dashboard aggregates application statistics by specialty and by cycle, allowing researchers to track how many applicants to a given specialty also designated applications to other specialties in the same cycle. By pulling these figures for each application year from 2022 through 2026, the research team was able to construct a five-year cross-sectional picture of dual-application behavior among dermatology applicants. Because the data are publicly available, the study required no institutional review board approval, and the authors have made supplemental methods and data available through a public repository to allow independent verification of their analysis.

The appeal of such an approach is its transparency. Rather than relying on surveys, which are vulnerable to recall bias and to the reluctance of applicants to admit hedging behavior, the ERAS dashboard captures what applicants actually did when they submitted their applications. That distinction matters, because dual applications are a sensitive topic. Advisors and program directors have debated for years whether applying to two specialties signals genuine interest in both fields or a lack of commitment to either, and whether such applications dilute the applicant pool or simply reflect rational behavior under uncertainty. Administrative data sidestep those confessions and report the behavior directly.

The context in which this research appears is one of mounting pressure on the residency pipeline. The Association of American Medical Colleges has repeatedly projected a continuing shortage of physicians in the United States, a forecast that has intensified scrutiny of how medical students choose specialties and how residency programs select trainees. At the same time, the total number of applications submitted per applicant has risen across many specialties, a phenomenon that has been criticized for inflating competition and straining program review capacity. Against that backdrop, dual applications occupy an ambiguous position: from the applicant’s perspective they are a risk-management tool, but from the perspective of specialties and programs they complicate the interpretation of application numbers and may distort the apparent competitiveness of a field.

The ethical dimension of the trend has not gone unnoticed. A companion commentary by several overlapping authors, published in the Journal of the American Academy of Dermatology, explores the implications of dual-specialty applications for medical student advisors, raising questions about the duty advisors owe to students who are torn between fields, and about the fairness of a system in which well-advised students can hedge while others cannot. The research letter and the commentary together frame dual applications not merely as a statistical curiosity but as a structural feature of the match ecosystem that deserves deliberate policy attention rather than informal folklore.

For dermatology specifically, the stakes are concrete. Program directors rely on application data to gauge interest, to set screening thresholds, and to decide how to allocate interview invitations. If a meaningful fraction of dermatology applicants are simultaneously pursuing another specialty, the raw applicant count may overstate the number of candidates who would actually accept a dermatology position, while the number of applications per applicant may inflate the workload of reviewing programs. Conversely, applicants who dual apply face their own dilemmas: how to present a credible narrative of commitment to two different fields, how to schedule audition rotations and letters of recommendation across specialties, and how to answer the inevitable interview question about which specialty they truly prefer.

The study’s timeframe is itself significant. The 2022 to 2026 window spans a period of unusual turbulence in graduate medical education, encompassing the aftermath of the pandemic-era shift to virtual interviews, ongoing debates about the role of United States Medical Licensing Examination scores in screening, and growing adoption of holistic review practices that de-emphasize quantitative metrics in favor of broader assessment of candidates. Each of these shifts alters the calculus that applicants use when deciding whether to hedge. A student who might once have relied on a strong Step score to secure dermatology interviews may now face more uncertainty about how they will be evaluated, and uncertainty is precisely the condition that drives dual applications.

The researchers also situate their work within a broader effort to demystify the dermatology application process. A recent multi-part series in Clinics in Dermatology has examined the path forward for the specialty, including holistic review, equity and inclusion, and post-match solutions, reflecting a specialty-wide recognition that the current system produces stress for applicants and inefficiency for programs. The new ERAS dashboard analysis contributes an empirical baseline to that conversation: before stakeholders can evaluate whether dual applications are rising, stabilizing, or falling, and before they can design interventions, they need reliable descriptive data on the scale of the phenomenon. That is precisely what a cross-sectional analysis of five consecutive application cycles provides.

What emerges from the study is a portrait of a specialty at an inflection point. Dermatology remains a destination field, but the behavior of its applicants reveals the strategic adaptations that extreme competition produces. Dual-specialty applications are the visible signature of that adaptation, and the ERAS specialty dashboard offers a way to monitor it year by year without burdening applicants with additional surveys. The authors, who report no funding and no competing interests, frame their work as a descriptive contribution intended to inform advisors, program directors, and national organizations as they weigh reforms to the application process. Whether the appropriate response is better advising, changes to how programs screen applications, or structural reforms to the match itself remains an open question, but the study makes clear that the question can no longer be answered anecdotally. With public data now covering half a decade of applicant behavior, the conversation about dual applications in dermatology can move from speculation to evidence, and the specialty can begin to decide whether hedging is a problem to be solved or simply a rational response to a system that applicants did not design.

Subject of Research: Dual-specialty residency application trends among dermatology applicants in the ERAS system

Article Title: Trends in dual-specialty applications among dermatology applicants: a cross-sectional analysis from 2022 to 2026 of the ERAS specialty dashboard

Article References: Fleshner, L., Moon, J., Klufas, T., Zhou, A. E., Grant-Kels, J. M., & Klufas, D. M. (2026). Trends in dual-specialty applications among dermatology applicants: a cross-sectional analysis from 2022 to 2026 of the ERAS specialty dashboard. Archives of Dermatological Research, 318(1), Article 523. https://doi.org/10.1007/s00403-026-04996-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04996-8

Keywords: dermatology, residency match, ERAS, dual-specialty applications, medical education, NRMP, AAMC, application trends, physician workforce, holistic review, international medical graduates, USMLE

The clinical context explains why timing matters so much. Large tumours of the oral cavity often leave what surgeons call volume defects, gaps in tissue that must be reconstructed with flap transfers, in which a segment of tissue, sometimes with its own blood supply, is moved to rebuild the affected area. After such operations, patients cannot eat normally while the wounds and swallowing musculature heal. Roughly 60 percent of head and neck cancer patients are already malnourished at presentation, and poor nutrition is an independent risk factor for surgical complications, morbidity and mortality. Every additional day of fasting therefore compounds an existing problem, deepening the metabolic stress that major surgery already imposes on the body.

Enhanced recovery after surgery, or ERAS, is the modern framework designed to counter that stress. These multimodal perioperative pathways combine early mobilisation, standardised anaesthetic and analgesic regimens, and careful nutritional optimisation, and they have been shown to shorten hospital stays and reduce costs. A central ERAS principle is avoiding prolonged fasting: solids are permitted up to six hours before anaesthesia, and fluids, including carbohydrate-loading drinks, up to two hours before. The ERAS Society consensus guidelines for head and neck surgery recommend that postoperative tube feeding should begin within 24 hours of surgery in patients who cannot yet tolerate oral intake. The most recent guidance from ESPEN, the European Society of Parenteral and Enteral Nutrition, goes further, stating that oral or tube feeding should start as soon as possible within the first few hours after surgery in conscious and haemodynamically stable patients.

The physiological rationale is well established. Prolonged preoperative fasting raises the risk of hyperglycaemia, metabolic stress and insulin resistance, the hallmark of the catabolic response to injury. Carbohydrate loading before surgery has been shown to blunt postoperative insulin resistance, reduce protein and nitrogen losses, improve muscle function and shorten length of stay. Early postoperative nutrition works in the same direction, limiting nitrogen and muscle loss during the critical healing window. Evidence from gastrointestinal surgery, where most of this research has been conducted, has found no benefit to keeping patients nil-by-mouth, and a Cochrane review concluded that early enteral nutrition reduced hospital stay by almost two days, with no differences in complications, including pneumonia, and only weak evidence of increased vomiting.

What remained unclear was whether these findings translate to head and neck flap surgery, where the airway, the swallow and a freshly transplanted flap all sit in close proximity. Few studies have examined the timing of tube feeding in this population, and a gap existed specifically around feeding earlier within the 24-hour window, including on the same day as surgery. The UCLH team, led by head and neck dietitian Florence Cook together with oral and maxillofacial surgeons and perioperative medicine consultants, set out to close that gap using the Plan-Do-Study-Act cycle, the four-stage improvement model, borrowed from industrial engineering, in which a change is planned, tested, studied and then adapted or adopted.

The planning stage revealed both an opportunity and a hidden inefficiency. Although the unit’s existing ERAS protocol already required feeding within 24 hours, the usual practice was to wait until the morning surgical review before commencing feeds. Discussions among stakeholders noted that operating finish times had improved, with midnight finishes now uncommon, making same-day feeding more feasible. Patient and public involvement feedback added that earlier feeding might support the energy levels patients need to mobilise the next day. The team also spotted that many patients were being sent for a chest x-ray to confirm nasogastric tube position before anyone attempted a pH aspirate test, contrary to national guidance that specifies pH testing first. Five of seven consultants agreed to trial early enteral nutrition; two declined, citing concerns about the risk-benefit ratio and nausea or vomiting. High-risk patients, such as those at risk of vomiting or delayed gastric emptying, were excluded at the operating surgeon’s discretion.

The protocol that emerged after three rounds of revision was deliberately conservative in one respect: the feed itself did not change. Patients received the established starter regimen, a 1.5 kcal/ml standard polymeric formula beginning at 20 ml per hour and increasing in 30 ml per hour steps as long as gastric aspirates stayed below 200 ml, with target rates scaled to body weight. A pre-written electronic record template ensured feeding instructions were consistent. The protocol was approved through clinical governance and rolled out on 27 May 2025, with prospective data collected over six months on fasting times, nutritional intake, complications graded by the Clavien-Dindo system, length of stay and weight change.

The results were striking. Of 45 included patients, 23 received early enteral nutrition and 22 received usual care. The early group’s median perioperative fasting time was 0.7 days compared with 1.3 days in the usual group, and feeding began a median of 4.3 hours after surgery versus 18.5 hours, differences that were highly statistically significant. Within the first 24 hours, the early group received a median of 215 ml of feed, delivering 322.5 kcal and 13.5 g of protein, while the usual-care group received nothing. Weight loss at discharge was also markedly lower in the early group, a median of 1 percent versus 5.6 percent. Crucially, safety signals were reassuring: there were no significant differences in Clavien-Dindo complications of grade three or above, in vomiting during the first 24 or 72 hours, or in gastric aspirates. Length of stay was similar between groups, and 96 percent of all patients met the ERAS target of feeding within 24 hours, an adherence rate higher than reported in previous studies.

The authors are careful about what these numbers can and cannot show. The project was a non-randomised, single-centre quality improvement exercise with a small sample and a short timeframe, so causation cannot be established and the findings may not generalise to every unit. Six patients recommended for early feeding did not receive it, for reasons including an immediate return to theatre and displaced feeding tubes, and the usual-care group contained more sarcoma cases. Even so, the pattern aligns with a growing international literature: a Japanese before-and-after study found early feeding on postoperative day one was safe and feasible without increased complications, and a randomised trial of feeding started during the operation itself reported no excess adverse events or flap failure, with some indication of enhanced wound regeneration.

The practical consequences of the project extend beyond the feeding schedule. In the Act phase of the cycle, the findings were presented to the wider surgical team, who agreed to establish early enteral nutrition as an option in the local ERAS protocol. The audit also exposed the overuse of chest x-rays for tube position checking: only 16 percent of patients had a pH aspirate attempted first, and the early-feeding group needed fewer x-rays overall, 53 versus 73, prompting further improvement cycles. The team now calls for high-quality randomised trials to confirm the safety and potential metabolic benefits of very early feeding in head and neck surgery, and for a mapping exercise of current practice, noting that as fast-track protocols become usual care, such trials may become difficult to run. For now, the message for patients facing flap reconstruction is a simple one: the era of waiting until the morning after surgery for the first calories may be coming to an end.

Subject of Research: Timing of early enteral nutrition after reconstructive head and neck flap surgery

Article Title: Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle

Article References: Cook, F., Niemann, A., Ambler, G., Sahovaler, A., & Ward, P. (2026). Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle. Supportive Care in Cancer, 34(10), Article 1008. https://doi.org/10.1007/s00520-026-11231-7

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11231-7

Keywords: head and neck cancer, flap reconstruction, enteral nutrition, ERAS, enhanced recovery, quality improvement, Plan-Do-Study-Act, nasogastric feeding, perioperative nutrition, fasting, Clavien-Dindo complications, Supportive Care in Cancer

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: Stewart, C. L., Ituarte, P. H. G., Tran, T., Lin, J., Buga, S., Sullivan, M. J., Schoellhammer, H. F., Melstrom, L., Paz, I. B., Sun, V., Fong, Y., & Woo, Y. (2026). 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. BMC Cancer. 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 physiological case for specialized care begins long before the first incision. Even in the absence of overt disease, aging produces organ-specific changes that erode physiological reserve and impair homeostasis. Cardiovascular stiffness reduces the heart’s ability to buffer the stress of anesthesia, declining renal function prolongs the elimination of drugs and their metabolites, and age-related shifts in body composition alter how anesthetic agents are distributed and cleared. The authors emphasize that these changes mean older patients are exquisitely sensitive to both under- and over-treatment: too little hemodynamic support risks organ injury, while excessive sedation or fluid loading can tip a fragile balance into delirium, kidney failure, or prolonged recovery. Dosing, the 2025 American Society of Anesthesiologists advisory makes clear, should be individualized according to physiological rather than chronological age.

One of the review’s most counterintuitive findings concerns preoperative testing. Despite the multiple comorbidities typical of geriatric patients, one study found that only 12.9 percent presented significant abnormalities in preoperative blood tests, and laboratory findings were not significant predictors of postoperative complications. Excessive testing, the authors warn, may increase distress and delay time-sensitive surgery without improving outcomes. Instead, the evidence supports a targeted approach: a thorough history and physical examination should guide which investigations are actually needed. Resting electrocardiography is recommended for patients aged 65 and over undergoing intermediate- or high-risk surgery, echocardiography is reserved for suspected valvular disease or unexplained dyspnea, and routine stress testing before low-risk procedures is explicitly not recommended. In emergency surgery, where mortality and complication rates are substantially higher, evaluation should focus only on factors that will immediately influence management.

Cardiac risk assessment occupies a central place in the review, and here the authors highlight a critical gap. The Revised Cardiac Risk Index, long the workhorse of perioperative cardiology, incorporates six variables including ischemic heart disease, heart failure, and high-risk surgery. Yet growing evidence suggests that in patients aged 80 and above, the RCRI may systematically underestimate perioperative cardiac risk. To compensate, contemporary guidelines recommend biomarker surveillance: preoperative B-type natriuretic peptide measurement for older patients facing intermediate- or high-risk surgery, and high-sensitivity cardiac troponin measured before surgery and at 24 and 48 hours afterward. The rationale is compelling—perioperative myocardial injury is frequently asymptomatic, and even modest postoperative troponin elevations are independently associated with increased short-term mortality. However, the authors caution that biomarker thresholds have largely been validated in mixed-age populations, leaving their optimal application in the oldest patients uncertain.

Beyond the heart, the review identifies frailty as perhaps the single most important concept in modern geriatric perioperative medicine. Defined as a state of decreased physiological reserve and increased vulnerability to stressors, frailty predicts postoperative complications, prolonged hospitalization, institutionalization, loss of independence, and death more powerfully than age itself. The Clinical Frailty Scale, a simple scoring tool with demonstrated interrater reliability among perioperative clinicians, is emerging as a candidate for routine incorporation into standard preoperative evaluation. Closely related is sarcopenia—low muscle strength, reduced muscle mass, and impaired physical performance—which a meta-analysis of 43 studies linked to a fourfold increase in postoperative complications and a doubling of 30-day mortality after gastroenterological cancer surgery. Crucially, both conditions should be regarded as potentially modifiable rather than fixed: multimodal prehabilitation combining exercise, nutritional optimization, and medication review has been shown in meta-analyses to improve muscle mass, strength, gait speed, and postoperative outcomes in frail older patients.

Nutrition emerges as another underappreciated pillar of preoperative preparation. Malnutrition affects up to 22 percent of hospitalized older adults and 30 percent of those in long-term care, and the surgical period compounds the problem through increased catabolism, reduced appetite, gastrointestinal dysfunction, fasting requirements, and the deleterious effects of medications. Body mass index, the review notes, has limited utility in this population because fluid retention and altered body composition can mask true deficits. Validated screening tools fill the gap: the Nutritional Risk Screening 2002, derived from surgical trial data and endorsed by the American Association for the Surgery of Trauma, the simpler two-parameter Geriatric Nutritional Risk Index, and the widely used Mini Nutritional Assessment, which a recent meta-analysis of over 200,000 geriatric orthopedic patients linked to postoperative complications and mortality. Patients flagged as high risk warrant preoperative counseling, oral nutritional supplements, and, in severe cases, consideration of postponing elective surgery.

Cognitive function and mental health receive equally detailed attention. Cognitive screening should be a routine component of preoperative evaluation, with the three-minute Mini-Cog offering a practical balance of brevity and predictive value for postoperative delirium, while the Montreal Cognitive Assessment and Mini Mental State Examination serve as alternatives with different practical constraints. The review also flags sensory deficits—hearing and vision loss—as independent predictors of delirium, citing a cohort study in which patients deprived of hearing aids and glasses throughout the perioperative period had higher rates of delirium and lower quality-of-recovery scores. Depression, present in up to half of surgical patients, is associated with worse outcomes, yet screening remains inconsistent; one UK prospective study found that two-thirds of patients who screened positive for depression accepted referrals to mental health care. Sleep disturbances, too, contribute to worse cognition, greater pain perception, and falls.

Medication management is framed as a continuous thread running from admission to discharge. Polypharmacy, commonly defined as five or more concurrent medications, is nearly universal among older surgical patients and carries a cumulatively unfavorable benefit-to-risk profile. The STOPP/START criteria and the American Geriatrics Society Beers Criteria offer structured ways to identify potentially inappropriate medications and prescribing omissions, and a brief preoperative review can flag high-risk patients for geriatric referral. Anticoagulants and antiplatelet agents demand particular care: interruption balances procedural bleeding risk against thromboembolic danger, a calculation complicated in the oldest patients by declining renal function that prolongs the elimination of agents such as dabigatran. Discharge represents a second opportunity, when prescribing physicians should reconcile medication lists and deprescribe what was flagged preoperatively.

In the operating room and intensive care unit, the review’s technical recommendations center on hemodynamic stability and anesthetic depth. Intraoperative and postoperative hypotension are associated with myocardial injury, acute kidney injury, stroke, and death, and prolonged or profound blood pressure drops should be avoided whenever possible. Excessive depth of anesthesia, monitored with electroencephalography-based tools such as bispectral index, may contribute to delayed recovery and neurocognitive complications. Regional anesthetic techniques do not show consistent superiority over general anesthesia for mortality or delirium, but may reduce opioid exposure in selected patients. After surgery, enhanced recovery protocols—early mobilization within 24 hours, carbohydrate-containing oral hydration up to two hours before surgery, and early urinary catheter removal—have been shown in meta-analyses of older orthopedic and colorectal patients to reduce complications and shorten hospital stays, though epidural analgesia raises the risk of urinary retention with early catheter removal.

The final and arguably most sobering section addresses what happens after discharge. Postoperative delirium affects up to 50 percent of older surgical patients, compared with 2 to 3 percent of the general population, and a systematic review of more than 20,000 patients linked it to increased mortality, prolonged hospitalization, non-home discharge, and intensive care admission; its economic burden in the United States is estimated at roughly 164 billion dollars annually. Non-pharmacological prevention—geriatric consultation, cognitive stimulation, sensory aid preservation, treatment of underlying causes—remains first-line management, while antipsychotics carry safety concerns and benzodiazepines may worsen outcomes. Nearly 30 percent of older patients experience functional decline in the perioperative period, and for some the decline is irreversible. With no universally recognized post-discharge pathways and ongoing trials still underway, the authors conclude that individualized care plans built by interdisciplinary teams—surgeons, anesthetists, geriatricians, nurses, and rehabilitation specialists—are not a luxury but a necessity for a population whose numbers will only grow.

Subject of Research: Perioperative management of very old surgical patients, focusing on frailty, geriatric syndromes, and individualized interdisciplinary care

Article Title: Perioperative care in older adults: a narrative review

Article References: Szczeklik, W., Pasieka, P., Piotrowicz, K., & Włudarczyk, A. (2026). Perioperative care in older adults: a narrative review. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01617-5

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01617-5

Keywords: perioperative care, older adults, frailty, sarcopenia, delirium, preoperative assessment, cardiac risk, malnutrition, polypharmacy, prehabilitation, ERAS, geriatric surgery

The findings, led by Neil S. Zhang and Atif Qasim of the University of California, San Francisco, along with collaborators at Creighton University and the Kirk Kerkorian School of Medicine at UNLV, are striking in their clarity. Overall, 32,091 of the 38,179 applicants, or 84.1 percent, successfully entered the subspecialty to which they applied. But that aggregate success rate conceals dramatic differences among applicant groups. Research productivity emerged as the single most powerful predictor: applicants with 11 or more publications had 4.18 times higher odds of success compared with those who had none, a stronger association than any other characteristic examined.

The study leveraged a unique combination of databases. Applicant characteristics came from the Electronic Residency Application Service, or ERAS, administered by the Association of American Medical Colleges, and were linked to the AAMC’s Graduate Medical Education Track, a national registry of trainees at every residency and fellowship program. An applicant was defined as successful if he or she appeared in GME Track as a fellow in the same subspecialty during the corresponding appointment year. The researchers excluded applicants who applied to more than one subspecialty, applied in multiple years, or had masked ages, yielding a cohort of single-time applicants to cardiovascular disease, endocrinology, gastroenterology, hematology and oncology, infectious disease, pulmonary and critical care medicine, nephrology, and rheumatology.

Statistically, the team used multivariable logistic regression to isolate the effect of each characteristic while adjusting for all others, along with the subspecialty and application year. Predictive margins were estimated to calculate adjusted probabilities of success for different applicant groups across publication categories. The cohort had a median age of 31 years, and 41.2 percent were female, 9.5 percent identified as underrepresented in medicine, and 39.6 percent were international medical graduates. Chief resident status, additional graduate degrees such as a PhD or master’s degree, and training in larger residency programs with 55 or more residents all independently boosted the odds of success.

Against these advantages, several groups faced measurable headwinds. Each additional year of age was associated with lower odds of success. After adjustment, female applicants had 0.89 times the odds of success, underrepresented-in-medicine applicants 0.84 times, osteopathic DO graduates 0.53 times, and international medical graduates just 0.44 times the odds of their counterparts. Graduates of community-based residency programs and community-based, university-affiliated programs were likewise significantly less likely to succeed than those from university-based programs, a pattern the authors attribute in part to the weight program directors place on the perceived reputation of the training institution.

The subspecialty-level breakdown sharpened the picture. The disadvantage for female applicants was most pronounced in cardiovascular disease and gastroenterology, where women had 0.79 times the odds of success, while the penalty for underrepresented-in-medicine applicants was especially evident in pulmonary and critical care medicine, at 0.59 times the odds. The payoff for research output also varied: the association between 11 or more publications and success was particularly strong in gastroenterology, pulmonary and critical care medicine, and endocrinology, though notably absent in infectious disease. Analyses restricted to the four most competitive subspecialties suggested that many of these disadvantages grew even larger in the toughest markets.

One of the most consequential findings concerns whether publications can compensate for baseline disadvantage. Predictive margins showed that success rose with publication count for every applicant group. For underrepresented-in-medicine applicants, the gap with non-underrepresented peers appeared to narrow at higher publication counts, although interaction testing did not reach statistical significance, likely because few such applicants reached the highest publication category. More sobering was the finding that the disadvantages experienced by female and DO applicants persisted at every level of research productivity, showing no attenuation whatsoever. International medical graduates gained more from each additional publication than their MD counterparts, yet even this larger benefit failed to erase their baseline gap entirely.

The authors frame these results as evidence of a self-reinforcing research arms race. Program director surveys consistently rank research involvement and perceived interest in scholarship among the most important selection factors, prompting applicants to accumulate ever more publications, which in turn pushes programs to value the metric even more. Prior work suggests many of these entries are never cited, raising concerns about the quality of the science behind the numbers. The ERAS publications variable aggregates journal articles, abstracts, book chapters, and presentations into a single count, so a first-author paper in a major journal currently carries the same statistical weight as a poster at a regional meeting, a limitation the researchers say should be addressed in future studies.

As a remedy, the study advocates for Mission-aligned Selection, a framework promoted by the AAMC that emphasizes individualized, systematic review of applicants’ experiences, attributes, and academic metrics in light of each program’s mission. Early adopters offer encouraging signals: after one pulmonary and critical care fellowship implemented holistic review practices, its faculty ranked publications among the least important metrics, and a pediatric surgery fellowship reported that the caliber of its interviewees actually improved. The authors also point to preference signaling, now available in several internal medicine subspecialties, as a tool that may reduce defensive over-application, though its effects on equity remain unproven. They caution that qualitative materials central to holistic review, such as letters of recommendation, have been shown to contain biased language toward female and underrepresented applicants, so standardization efforts must accompany any shift away from raw publication counts.

The study’s limitations are worth noting. Because direct match data were not available, success was defined as entering the subspecialty rather than formally matching, though out-of-match placements likely represent a small minority. Factors such as board scores, honors, interview ratings, and personal statements were unavailable, leaving room for residual confounding. Still, as the first comprehensive, individual-level national analysis of its kind, the work makes the structure of the fellowship selection process unusually visible. Its message is twofold: research output overwhelmingly determines who gets in, and the system as currently constituted systematically favors younger, male, non-underrepresented, US MD graduates at large university programs. Whether programs and their governing bodies embrace mission-aligned processes may determine not only individual careers but also the future diversity and representativeness of the internal medicine subspecialty workforce.

Subject of Research: Factors associated with successful entry into internal medicine subspecialty fellowships

Article Title: Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships

Article References: Zhang, N. S., Tun, K. M., Batra, K., Babik, J. M., Huppert, L., Singh, A., Wahi-Gururaj, S., & Qasim, A. (2026). Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10688-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10688-w

Keywords: internal medicine, fellowship match, graduate medical education, publications, underrepresented in medicine, international medical graduates, osteopathic medicine, mission-aligned selection, ERAS, cardiology, pulmonary critical care, workforce diversity