The study, conducted by Karin Falk-Brynhildsen, Carina Bååth, Dimitri Beeckman, Christine Leo Swenne, Charlotte Raepsaet and Camilla Wistrand, set out to describe Swedish operating room nurses’ self-estimated knowledge and attitudes regarding the prevention of intraoperative pressure ulcers. Using a cross-sectional design reported according to the STROBE guidelines for observational studies, the team distributed an online questionnaire by email to operating room nurses across all 21 of Sweden’s healthcare regions. Of the 2247 addresses contacted, 343 proved non-functional, leaving 1904 eligible recipients. After two reminders, 284 nurses completed the survey, a response rate of 15 percent. Data collection took place in August and September 2020 as part of a larger project developing two validated instruments tailored to the operating room: the Pressure Ulcer Knowledge Assessment Tool for the operating room, known as PUKAT 2.0 OR, and the Attitudes toward Pressure Ulcer Prevention instrument adapted for the same setting, the APuP-OR.

The scale of the clinical problem provides the context for why this matters. According to the European Pressure Ulcer Advisory Panel guidelines, surgery-related pressure ulcers occur in approximately 4 to 45 percent of surgical procedures. Recent studies have documented intraoperative incidence rates ranging from 6.2 to 16.2 percent, and one study of patients aged 65 and older reported an incidence of 18.8 percent, with operative times of 180 minutes or longer strongly associated with increased risk. Medical devices compound the danger: blood pressure cuffs, adhesive tapes, endotracheal tubes and spectral index monitors can all damage skin and mucosal surfaces, and device-related pressure ulcers have been estimated at a prevalence of around 11.8 percent, while positioning-related ulcers may reach 23.5 percent. The operating room is therefore recognised as a high-risk environment where every member of the surgical team shares responsibility for tissue protection.

The 284 respondents were an experienced and highly educated group. Their mean age was 42.8 years, 93 percent were women, and 37 percent held a master’s degree while another 33.8 percent held a professional operating room nursing degree. More than 63 percent had over 11 years of experience in healthcare, and 37.7 percent had more than 20 years. When asked to rate their own expertise using Benner’s classic proficiency levels, half identified as proficient and 38 percent as competent, with 11.3 percent claiming expert status and only two nurses describing themselves as novices. Crucially, 87 percent said that further education in pressure ulcer prevention would be beneficial, an appetite for learning that the study’s findings suggest is well founded.

The knowledge assessment told a story of two halves. In the domain of aetiology, the nurses performed impressively. More than 95 percent correctly identified the causes of pressure ulcers and understood the biomechanical consequences of a patient sliding in a semi-upright position, and 90.1 percent recognised that body weight contributes to risk. These results align with previous research emphasising the role of knowledge in delivering evidence-based care. But when the questions turned to prevention, classification and observation, performance dropped sharply. Only 38 percent correctly identified where deep tissue injuries develop during surgery, and just 41.2 percent correctly classified blisters observed on both heels after a three-hour procedure. Nearly 60 percent answered incorrectly when asked about heel protection measures for a patient already lying on a pressure-redistributing mattress, and questions about patient positioning yielded correct response rates of only around 51 to 52 percent.

The researchers applied a demanding benchmark to these results, using a 90 percent threshold for correct answers, and only 3 of the 14 knowledge items met it. Even when the cut-off was lowered to 70 percent, the number of adequate responses remained limited. The authors deliberately retained the stricter threshold, reflecting on whether adjusting the standard of what counts as sufficient knowledge in pressure ulcer prevention is appropriate at all. The finding that positioning competencies are limited is consistent with earlier work by Sørensen and colleagues, who reported similar gaps among surgical teams, and it points to a specific, teachable weakness at the heart of intraoperative care: knowing how to position a patient safely is not the same as knowing why pressure damages tissue.

Attitudes, by contrast, were overwhelmingly positive. A remarkable 94.7 percent of respondents reported feeling confident in their ability to prevent pressure ulcers, and 98.6 percent agreed that prevention should be a priority and a personally important responsibility. Fully 94 percent acknowledged the financial burden that pressure ulcers place on society. The nurses firmly rejected dismissive statements: 93.7 percent disagreed that the impact of pressure ulcers on patients is exaggerated, 96.5 percent rejected the notion that too much attention is paid to prevention, and 96.1 percent refused the idea that they bear no responsibility if an ulcer develops in their patient. Attitude scores were higher than those reported in a previous study by Khong and colleagues, suggesting Swedish operating room nurses occupy an unusually favourable motivational position.

Experience shaped confidence in measurable ways. Pairwise comparisons revealed statistically significant differences across years of operating room experience in perceived training: nurses with more than 20 years of experience felt significantly better trained than those with 5 to 10 years, with a p-value of 0.049. A similar pattern emerged for perceived confidence, with significant differences between the most experienced nurses and those with 5 to 10 years of experience, and between the 11-to-20-year group and their less experienced colleagues. Yet the study’s central paradox remains: despite this confidence and experience, overall knowledge was insufficient, and positive attitudes did not translate into consistently correct answers about prevention strategies such as surgical linen use, positioning angles and heel offloading.

The authors are candid about the limitations of their work. Self-reported data are vulnerable to recall bias and social desirability bias, and some question wording may have confused participants. The 15 percent response rate restricts generalisability, and it is possible that respondents were more interested in pressure ulcer prevention than non-respondents, which could have inflated the apparent knowledge and attitude scores. The measurement instruments themselves, while validated, showed modest internal consistency on some subscales, and the authors note that PUKAT 2.0 OR requires further refinement to capture the complexity of pre-positioning across different surgical procedures while preserving operative exposure for the surgeon.

The implications reach beyond Sweden. Because most pressure ulcers are preventable, the authors argue, raising awareness and promoting evidence-based prevention strategies across the entire operating room team is imperative, including surgeons, anaesthesiologists and nurse anaesthetists, not nurses alone. They call for systematic, evidence-based educational interventions, structured training programmes, simulation-based learning and regular competency assessments integrated into continuing professional development, alongside mixed-methods research to clarify why positive attitudes fail to produce adequate knowledge or consistent preventive action. Structured risk assessment tools, which guidelines consider the gold standard, should complement rather than replace clinical judgement. For a complication that can begin forming the moment a patient is positioned on the table, the message of this survey is clear: the will to prevent pressure ulcers is present in the operating room, but the knowledge to do so reliably still needs to be built, one training programme at a time.

Subject of Research: Operating room nurses' knowledge and attitudes regarding intraoperative pressure ulcer prevention

Article Title: Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes

Article References: Falk‐Brynhildsen, K., Bååth, C., Beeckman, D., Leo Swenne, C., Raepsaet, C., & Wistrand, C. (2026). Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes. Nursing Open, 13(9), Article e70808. https://doi.org/10.1002/nop2.70808

Image Credits: AI Generated

DOI: 10.1002/nop2.70808

Keywords: pressure ulcers, operating room nurses, patient safety, intraoperative care, nursing knowledge, survey research, Sweden, patient positioning, surgical complications, nursing education, pressure injury prevention, cross-sectional study

The subject of this comprehensive case report involved a fatal overdose incident wherein atomoxetine was identified as the primary agent responsible for death. The forensic examination revealed a complex interplay of pharmacodynamic and toxicokinetic factors that culminated in fatal cardiotoxicity and central nervous system complications. Given atomoxetine’s widespread utilization as an alternative to stimulant ADHD medications, this case challenges previously held assumptions regarding its safety profile and establishes a critical precedent for future clinical toxicology contexts.

Atomoxetine’s mechanism of action centers around selective norepinephrine reuptake inhibition, resulting in increased extracellular norepinephrine levels, which modulate attention and behavior. Nonetheless, at supra-therapeutic dosages, this same mechanism can provoke severe sympathomimetic effects, including tachycardia, hypertension, and arrhythmogenic potential. The forensic analysis detailed in the report demonstrated evidence of profound cardiac stress, including histopathological signs consistent with myocardial ischemia and arrhythmia-induced myocardial injury. These findings highlight the molecular and cellular consequences of overdose that transcend simple overdose symptomatology.

Moreover, the central nervous system effects observed during the autopsy documented cerebral edema and neuronal necrosis, indicating that atomoxetine overdose contributes not merely to cardiac events but also to neurotoxicity. This dual impact on multiple organ systems elucidates why atomoxetine overdoses can escalate rapidly into fatal outcomes. Toxicological screening confirmed extraordinarily high serum levels of atomoxetine, exceeding those seen in previously documented non-fatal overdose cases, which reinforces the dose-dependent risk of systemic toxicity.

The investigation also shed light on critical gaps in emergency response protocols, especially concerning diagnostic challenges in identifying atomoxetine as the causative agent in overdose scenarios. Since the clinical manifestations can mimic other sympathomimetic toxidromes, reliance solely on clinical symptoms may delay appropriate intervention. Consequently, the case advocates for enhanced screening methodologies incorporating advanced analytical toxicology techniques, such as liquid chromatography-tandem mass spectrometry (LC-MS/MS), to accurately quantify atomoxetine concentrations in biological specimens.

This forensic case, while singular, generates broader public health implications. With ADHD diagnoses rising globally and atomoxetine prescriptions increasing correspondingly, there is a looming potential for inadvertent or intentional overdoses. The case highlights the necessity for medical practitioners to educate patients regarding the risks of misuse and the early warning signs of toxicity. Equally, pharmacy policies should incorporate stringent safeguards to limit the availability of large quantities of atomoxetine to avoid potential overdose risks.

Notably, the case report delves into the pharmacogenetic factors that may exacerbate susceptibility to toxicity. Variations in cytochrome P450 2D6 enzyme activity, responsible for metabolizing atomoxetine, can lead to altered drug clearance rates, resulting in accumulation and toxicity even at lower dosages. Genetic polymorphism screening may thus become an essential consideration in personalized medicine models to mitigate adverse drug reactions.

Additionally, this research calls attention to the current limitations in clinical guidelines for treating atomoxetine overdose. Standardized protocols remain elusive, with supportive care dominating management strategies. Based on autopsy findings indicating cardiac and neurological involvement, tailored antidotal therapies targeting sympathetic overdrive and neuroprotection could become vital areas for future research and clinical trials.

The forensic autopsy report also emphasizes the importance of comprehensive death scene investigations and detailed medical histories to contextualize toxicological findings properly. Without careful reconstruction of events leading to death, attributing causality solely to atomoxetine overdose may be problematic, given the frequent presence of polypharmacy and comorbidities in such cases.

Furthermore, the analytical data derived from this single case could serve as a baseline for comparative studies, fostering enhanced understanding of atomoxetine’s toxicodynamics. Future toxicology databases should integrate these findings to improve postmortem diagnostic accuracy and guide public health policies regarding psychostimulant safety.

Importantly, the report delivers a cautionary narrative to the scientific community about the potential for emerging drug toxicities even among medications considered relatively safe. Such insights encourage ongoing pharmacovigilance and underscore the value of autopsy case reports as crucial tools in deciphering the real-world impacts of pharmaceutical agents.

In conclusion, this pivotal forensic autopsy case report from Japan illuminates the fatal threat posed by atomoxetine overdose, unraveling complex pathological processes and clinical challenges. It is a compelling call to action for enhanced clinical protocols, improved toxicological methodologies, and intensified educational efforts aimed at preventing overdose fatalities. As atomoxetine use becomes more entrenched globally, such detailed scientific inquiry will be essential for safeguarding public health and refining therapeutic strategies to balance efficacy with safety at all levels of care.

Subject of Research:

Article Title:

Article References:
Nara, A., Yamada, C., Kozakai, Y. et al. Fatal atomoxetine overdose in Japan: a forensic autopsy case report. Int J Legal Med (2025). https://doi.org/10.1007/s00414-025-03673-1

Image Credits: AI Generated

DOI: https://doi.org/10.1007/s00414-025-03673-1

Keywords:

Hemangioblastomas, generally classified as vascular tumors, are predominantly found in the cerebellum, brain stem, and spinal cord. The presence of such a tumor in the rectum is extraordinarily rare, which prompted extensive investigation and analysis. Researchers Zheng, Zhang, and Ma joined forces to document this peculiar case, highlighting the need for heightened awareness among healthcare professionals. Their meticulous examination aims to educate on the importance of differential diagnosis in cases presenting with rectal masses, especially in unexpected locations.

The patients’ journey began with symptoms that were mistakenly attributed to more common gastrointestinal disorders. Initially, complaints ranged from rectal bleeding to vague pelvic discomfort. These symptoms are frequently associated with benign conditions, which creates a significant diagnostic challenge for physicians. The authors emphasize that a thorough assessment, including imaging studies and biopsies, is crucial for accurate diagnosis, especially in atypical manifestations of tumors like hemangioblastoma.

Upon further investigation, imaging studies unveiled a mass located in the rectal area. The biopsy revealed the unique histological characteristics of hemangioblastoma, confirmed through immunohistochemical analysis. The tumor exhibited a distinctive vascular proliferation pattern, often confused with other neoplastic growths. The meticulous detail in histopathological analysis is underscored in this report, showcasing the rigorous standards applied in diagnosing rare tumors.

One of the most compelling aspects of this case is the etiology of the hemangioblastoma. Typically associated with von Hippel-Lindau syndrome, a genetic disorder that predisposes individuals to tumor development in various locations, the presence of a solitary hemangioblastoma in the rectum raises intriguing questions. The researchers conducted genetic analyses to explore potential links to hereditary syndromes, ultimately finding no evidence of the condition in the patient.

The treatment approach for this unique case included surgical excision of the neoplasm. This decision reflects the current understanding of hemangioblastoma management, which primarily revolves around complete surgical resection when feasible. The authors provide a comprehensive review of treatment paradigms for similar cases, highlighting the importance of patient-centered care tailored to individual circumstances.

In their review of the literature, the research team identified only a handful of documented cases of hemangioblastoma outside its conventional locations. By collating these instances, they contributed to the broader discourse surrounding the diagnosis and management of rare tumors. Such literature reviews are vital for advancing medical knowledge, particularly when it comes to understanding the myriad presentations of cancer.

The psychological aspect of a rare cancer diagnosis should not be overlooked. Patients often encounter confusion and fear when confronting unfamiliar terms and conditions. Zheng and colleagues emphasize the necessity of supportive counseling and psychological care as part of comprehensive cancer treatment. Patients diagnosed with such rare tumors require a robust support system to address their mental and emotional health alongside their physical treatment.

Looking towards the future, this case serves as a clarion call for ongoing research into rare cancers. The insights gained from this singular patient’s experience will undoubtedly contribute to a growing body of knowledge, potentially guiding future diagnostic protocols and treatment regimens. Investigations into the molecular mechanisms underlying hemangioblastomas could open avenues for targeted therapies, benefiting patients with these uncommon tumors.

As medical practitioners continue to encounter varied presentations of hemangioblastomas, continuous education and awareness are imperative. This case has propelled discussions on the pathological diversity of tumors, reinforcing the idea that rare does not mean insignificant. The medical community must remain vigilant and informed about such anomalies to ensure accurate diagnosis and timely intervention.

The collaboration between researchers and clinicians will be crucial moving forward. By sharing experiences and findings, they can collectively advance understanding in the field of oncology. As this case highlights, individual experiences may contribute greatly to the collective knowledge base, leading to improved outcomes for future patients.

In summary, the report of primary hemangioblastoma in the rectum marks a significant milestone in oncological literature. It captivates interest by blending clinical detail with the broader implications for patient care and medical education. As we forge ahead into an era of precision medicine, findings like these reaffirm the necessity of adaptability and ongoing inquiry in tackling the complexities of cancer.

The implications of this case extend beyond mere documentation; they challenge the existing narratives within oncology and shape future practice. It underscores the importance of interdisciplinary collaboration and continual learning in the quest to better understand and conquer cancer.

In essence, the case of primary hemangioblastoma in the rectum not only adds a unique entry to the annals of medical literature but also serves as a reminder of the importance of vigilance, creativity, and thoroughness in the ever-evolving landscape of cancer research and treatment.

Subject of Research: Primary hemangioblastoma of rectum

Article Title: Primary hemangioblastoma of rectum: a rare case report and review of literature

Article References:

Zheng, A., Zhang, S., Ma, Q. et al. Primary hemangioblastoma of rectum: a rare case report and review of literature.
J Cancer Res Clin Oncol 151, 322 (2025). https://doi.org/10.1007/s00432-025-06366-9

Image Credits: AI Generated

DOI: https://doi.org/10.1007/s00432-025-06366-9

Keywords: Hemangioblastoma, primary, rectum, rare tumors, case report, oncology