The research team, led by neurosurgeons at one of China’s most prominent hospitals, enrolled 147 consecutive patients between May 2018 and August 2020, ultimately analyzing 140 individuals who completed preoperative assessments: 98 with glioma, the most common primary malignant brain tumor, and 42 with brain metastases, most frequently originating from lung cancer. Every patient filled out two of the most widely used patient-reported outcome instruments in oncology, the EORTC QLQ-C30 core questionnaire and the brain-cancer-specific QLQ-BN20 module, before surgery and again at seven days, one month, and three months afterward. The QLQ-C30 captures five functional domains—physical, role, emotional, cognitive, and social—alongside global health status and a battery of symptoms, while the QLQ-BN20 probes issues particularly relevant to brain tumor patients, including future uncertainty, motor dysfunction, communication deficit, headaches, seizures, and leg weakness.

The headline result is a striking V-shaped trajectory in overall health status. One week after surgery, patients reported significant deterioration across multiple domains: global health status, physical function, role function, fatigue, pain, and lower extremity weakness all worsened compared with preoperative baselines. Among glioma patients, physical function fell from a mean of 87.4 points to 66.4 on the 100-point scale, and role function dropped from 79.6 to 60.8, both highly statistically significant declines. Yet by the one-month follow-up, most functional measures in the glioma group had climbed back to baseline levels, and the recovery pattern held across low-grade glioma, high-grade glioma, and brain metastasis subgroups, with high-grade patients recovering more slowly.

Not every symptom followed the same curve. For glioma patients, seizure-related symptoms actually improved one month after surgery, a finding the authors attribute to the clinical effect of removing epileptic foci during tumor resection, potentially reinforced by standardized anti-epileptic medication. In the brain metastasis group, psychological distress eased over time: future uncertainty and headaches were significantly alleviated at the one-month mark, and cognitive function scores improved as well. On the other hand, some symptoms emerged or lingered later in recovery—dyspnea and bladder control worsened at one month in glioma patients, skin itching deteriorated at three months, and dyspnea was significantly exacerbated at three months in the metastasis group.

Beyond charting trajectories, the study used multivariate linear regression to identify which patient and treatment characteristics independently predicted quality-of-life outcomes at each time point. The list of influential factors was long and domain-specific. Age, years of education, tumor location and laterality, surgical extent, and baseline Karnofsky Performance Status all emerged as significant predictors of particular HRQoL domains. For example, seven days after surgery, older age, more education, and right-sided tumors were independently associated with less severe communication deficit among glioma patients. At one month, tumors spanning multiple lobes, subtotal resection, and gross total resection were linked to worse motor dysfunction scores, while occipital lobe tumors predicted better motor outcomes.

Some associations defied simple intuition. Among glioma patients, advanced age was linked to milder communication deficits and leg weakness after surgery—a counterintuitive result the researchers attribute largely to selection bias. Elderly patients with severe preoperative neurological deficits or multiple comorbidities are generally not candidates for craniotomy, so the older patients who made it into the study represented a relatively healthy group with better neurological reserve. In the brain metastasis cohort, by contrast, older patients tended to report higher levels of future uncertainty and headaches, possibly reflecting the psychological weight and complex disease course that accompany metastatic cancer.

Tumor laterality produced some of the study’s most mechanistically interesting findings. Left-hemisphere lesions were associated with more severe baseline communication impairment, consistent with the left hemisphere’s dominant role in language processing. Right-sided tumors, meanwhile, were linked to worse emotional, cognitive, and social function in the early postoperative period. The authors note that these patterns align with the well-documented functional lateralization of the human cerebrum and argue that recognizing hemispheric differences can help clinicians design individualized assessment plans and targeted rehabilitation for speech, cognition, and motor function.

The Karnofsky Performance Status score, a standard measure of a patient’s ability to perform daily activities, proved to be a crucial reference point throughout. KPS was negatively correlated with headache, fatigue, and pain, meaning patients with better functional status reported fewer of these core symptoms. Baseline quality of life also differed significantly across tumor grades: patients with low-grade glioma, high-grade glioma, and brain metastases showed distinct profiles in physical function, cognitive function, pain, insomnia, motor dysfunction, headache, and leg weakness. Brain metastasis patients generally carried a heavier symptom burden at baseline, likely because most had already undergone systemic treatment for their primary tumors before arriving at neurosurgery.

The authors are candid about the study’s limitations. Follow-up attrition was substantial—only 33.7 percent of glioma patients and 31 percent of brain metastasis patients completed the three-month assessment—and the researchers used multiple imputation to manage missing data, though sensitivity analyses were not feasible given the sample size. The single-center design, the relatively short three-month window, and the absence of detailed records on preoperative systemic therapies and postoperative adjuvant treatments all introduce potential bias. The team also performed a large number of statistical tests across domains, time points, and subgroups, which elevates the risk of false-positive findings, and they caution that the observed associations are population-specific and require external validation in larger, multi-center cohorts.

Even with those caveats, the study’s practical message is clear and actionable. Surgery on a malignant brain tumor reliably produces a transient dip in quality of life, but for most patients the functional nadir is temporary, with the majority of indicators recovering within a month. Because age, tumor laterality, surgical approach, and performance status each shape different aspects of recovery at different times, the authors argue that regular, structured assessment of these factors can help clinicians formulate individualized interventions—whether targeted supportive care in the first postoperative week, seizure management, cognitive rehabilitation, or psychological support for patients grappling with uncertainty about the future. In a disease where median survival for glioblastoma remains between 12 and 15 months, ensuring that the time patients have is lived as well as possible is not a secondary goal but a central measure of treatment success.

Subject of Research: Perioperative health-related quality of life and its determinants in patients with malignant brain tumors

Article Title: Health-related quality of life and its determinants in patients with malignant brain tumors: a prospective longitudinal study

Article References: Xiao, Z., Chen, W., Yang, T., Wang, Y., Li, J., Guo, X., Wang, L., Xu, D., Jiang, W., Zhang, Y., Wang, Y., & Ma, W. (2026). Health-related quality of life and its determinants in patients with malignant brain tumors: a prospective longitudinal study. Supportive Care in Cancer, 34(10), Article 1021. https://doi.org/10.1007/s00520-026-11262-0

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11262-0

Keywords: malignant brain tumors, glioma, brain metastases, health-related quality of life, EORTC QLQ-C30, EORTC QLQ-BN20, neurosurgery, Karnofsky Performance Status, patient-reported outcomes, perioperative care, longitudinal study, supportive care

The concept behind the approach, known as prehabilitation, is deceptively simple. Surgery imposes an enormous metabolic and inflammatory burden on the body, and patients who enter the operating room with a larger physiological reserve — stronger hearts, lungs and muscles — are better equipped to absorb that stress and recover afterward. Rather than waiting until rehabilitation after surgery, when tissue damage, pain and fatigue make exercise far harder, prehabilitation front-loads the training into the preoperative period, when patients are often still physically capable of meaningful work. The idea has gained traction over the past decade, but evidence has remained fragmented across cancer types, outcome measures and study designs, and the specific contribution of exercise itself has often been obscured in multimodal programs that bundle it with nutrition and psychological support.

To isolate the exercise effect, the researchers restricted their analysis to unimodal exercise trials — programs of aerobic training, resistance training, or a combination of the two — compared against usual care or non-exercise control conditions. They excluded patients receiving neoadjuvant chemotherapy or radiotherapy, whose treatment-related toxicities would confound the results, and they registered the protocol prospectively. Searches across seven databases, supplemented by citation tracking that accounted for roughly 28 percent of the final included studies, yielded 28 articles representing 27 trials. The population skewed toward lung cancer, which accounted for 48.1 percent of studies, followed by gastrointestinal and genitourinary cancers, with a median patient age of 64 years.

The interventions themselves varied widely, reflecting the clinical reality that the time available before surgery can range from a single week to two months. Aerobic programs included treadmill walking, cycle ergometry, interval training and even high-intensity interval training, with intensities prescribed from moderate levels up to 115 percent of maximal cardiopulmonary exercise testing workload in some HIIT protocols. Resistance programs targeted major muscle groups with two to four sets per exercise at moderate to high intensity, while combined programs integrated both modalities. Most interventions — 74.1 percent — were supervised, and durations ranged from approximately one to eight weeks.

When the team applied a three-level mixed-effects meta-analysis, a statistical approach that accounts for multiple dependent effect sizes within the same study, the results were consistent in direction across the key physiological outcomes. Cardiorespiratory fitness, measured through cardiopulmonary exercise testing and related parameters, improved with a standardized mean difference of 0.31, driven almost entirely by preoperative gains. Physical function, assessed through validated performance tests such as the six-minute walk and timed up-and-go, showed the largest and most robust benefit at an SMD of 0.36, with the effect significant both before surgery and — critically — after it. Statistical heterogeneity was low for both outcomes, at 22.3 percent and 11.2 percent respectively, suggesting the benefits were remarkably consistent across different tests, cancer sites and exercise prescriptions.

The postoperative findings may be the most clinically consequential. Physical function typically deteriorates after major cancer surgery, and that decline is independently associated with poorer survival across the cancer care continuum. In this analysis, the functional gains achieved before surgery were not merely lost at the incision; they persisted, with postoperative physical function significantly better in the exercise groups than in controls. For the other outcomes, the pattern was one of preservation rather than improvement: cardiorespiratory fitness, muscle strength, fatigue and quality of life were maintained at or near baseline levels after surgery in exercising patients, effectively attenuating the expected perioperative decline. In perioperative medicine, holding ground is itself a victory.

Fatigue emerged as another notable beneficiary. While the overall effect across all time points did not reach significance, preoperative fatigue was significantly reduced, with aerobic exercise showing larger effects than combined training. This matters because cancer-related fatigue is among the most prevalent and burdensome symptoms in oncology, affecting daily functioning and treatment tolerance, and because fatigue and disability before surgery are associated with roughly a 50 percent higher risk of postoperative complications, including respiratory, cardiovascular and renal events. The authors suggest plausible mechanisms ranging from improved cardiorespiratory fitness and inflammatory regulation to enhanced self-efficacy.

Not every outcome responded equally. Muscle strength showed no significant overall improvement, though the analysis was limited to eight studies and the certainty of evidence was rated very low. Psychological distress was preserved rather than reduced, a finding that contrasts with some earlier meta-analyses and may reflect the shorter intervention durations, the standardized mean difference approach, or the possibility that meaningful mental health benefits require longer programs of six to eight weeks, higher baseline distress, or the addition of formal psychological support. Quality of life improved modestly overall, but the certainty of evidence was very low and small-study effects were detected, warranting caution. The authors themselves note that quality of life in patients awaiting major surgery is shaped by a web of physical, psychological, social and treatment-related factors that brief exercise programs alone are unlikely to transform.

The review is not without limitations, which the authors confront directly. The predominance of lung cancer trials, many involving thoracic procedures with high physiological demands, may limit generalizability. Surgical modality was inconsistently reported, obscuring a key driver of perioperative stress. The exclusion of patients on neoadjuvant therapy, while necessary to isolate the exercise-surgery interaction, leaves open the question for the growing population receiving systemic treatment before surgery. And most outcomes carried low or very low certainty of evidence under the GRADE framework, reflecting risk of bias, imprecision and small numbers of studies for several analyses.

Even so, the overall message is clear and increasingly actionable. Exercise-based prehabilitation appears safe and feasible across oncologic populations, improves the outcomes that matter most for tolerating surgery, and helps patients leave the hospital closer to — not further from — the functional condition they arrived in. The authors argue for a shift in perioperative cancer care toward interventions that prepare patients not just to survive the operation but to recover faster, mobilize earlier, and start adjuvant therapies like chemotherapy or immunotherapy on schedule. Exercise, they suggest, should be a cornerstone of that preparation, ideally embedded within individualized, periodized and multimodal care pathways that pair training with nutritional and psychological support tailored to each patient’s needs and timetable.

Subject of Research: Prehabilitative exercise before oncologic surgery

Article Title: Benefits of prehabilitative exercise on physiological, functional and patient-reported outcomes in patients undergoing oncologic surgery: A systematic review and meta-analysis

Article References: Casagrande, N., Singh, F., Rech, A., Radaelli, R., Paniz, B. M., Silvestro, G. T., Eberhardt, G. N., Brollo, J., Kneubil, M. C., Júnior, C. P., de Almeida, P. W. M., Magalhães, M. C. F., Bettariga, F., & Lopez, P. (2026). Benefits of prehabilitative exercise on physiological, functional and patient-reported outcomes in patients undergoing oncologic surgery: A systematic review and meta-analysis. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02107-0

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02107-0

Keywords: prehabilitation, cancer surgery, exercise, cardiorespiratory fitness, physical function, fatigue, quality of life, meta-analysis, perioperative care, oncology, randomized controlled trials, cancer survivorship

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 methodology behind the review was rigorous. The authors followed PRISMA guidelines, searching PubMed from database inception through August 2025 with terms combining Mohs micrographic surgery and patient satisfaction. Two independent reviewers screened the initial 183 records against predefined criteria, with disagreements resolved by consensus or a third reviewer. Eligible studies had to be peer-reviewed, published in English, conducted within the context of Mohs surgery, and designed to evaluate the effect of a perioperative intervention on patient satisfaction. The final set comprised fifteen randomized controlled trials, three retrospective observational studies, and one comparative study, with sample sizes ranging from just 24 participants to 1,250. Risk of bias was assessed independently by two reviewers using the National Institutes of Health Quality Assessment Tool, an important quality check given the heterogeneity of the underlying literature.

Measuring satisfaction proved to be a challenge in itself. The included studies employed a patchwork of instruments: twelve used Likert scales, two used patient satisfaction questionnaires, two used visual analog scales, two used investigator-developed surveys, and one used the FACE-Q Skin Cancer module. This instrument heterogeneity meant the authors could not pool results statistically and instead performed a qualitative synthesis. Perhaps the most striking finding, however, was not about any single intervention at all. Patient satisfaction was uniformly high across the board, regardless of what treatment patients received. The authors attribute this to a ceiling effect arising from the exceptionally high baseline satisfaction already observed in Mohs populations, where cure rates for primary basal cell carcinoma reach as high as 99 percent and 92 to 99 percent for squamous cell carcinoma.

Against that ceiling, four interventions broke through with statistically significant improvements in satisfaction. The first emerged in the preoperative phase: education using three-dimensional printed anatomical models. In a randomized trial by Biro and colleagues, 42 patients who received education via a 3D printed model of their own surgical anatomy showed improved procedural understanding, reduced preoperative anxiety, and significantly higher satisfaction on a Likert-type scale compared with 40 controls who received verbal education alone, a difference that reached statistical significance at p less than 0.03. The tactile and visual engagement of holding a physical replica of the surgical site appears to address multiple dimensions of the preoperative experience simultaneously, a quality that videos and pamphlets have struggled to replicate.

The second significant intervention was remarkably simple: letting patients look at their own surgical defect in a mirror before reconstruction begins. In a multicenter prospective cohort study, Veldhuizen and colleagues found that patients who viewed their facial skin cancer defect prior to closure reported dramatically higher satisfaction with their appearance, with an odds ratio of 8.66, and the effect persisted at twelve-month follow-up. This finding challenges the intuition that seeing a wound might be distressing. Instead, it appears that confronting the reality of the defect before it is repaired helps patients calibrate their expectations and appreciate the reconstruction, a form of psychological inoculation against the shock of the immediate postoperative appearance.

The third winning intervention targeted a sensory detail most surgeons never consider: smell. Because Mohs patients are awake, the acrid burning odor of electrocautery can be an unpleasant and memorable part of the procedure. In a cleverly designed comparative study, researchers attached a smoke evacuator to the electrocautery pen and activated it only during the closure stage, while maintaining the vacuum sound throughout all stages of the operation to preserve blinding. The results were dramatic. All patients perceived a burning odor during excision compared with only 40 percent during closure, patients were far less likely to report an unpleasant smell when the evacuator was active, 66.6 percent versus 16.6 percent at p less than 0.0001, and 76.7 percent rated the closure stage as more pleasant. Sometimes the difference between a good and bad surgical memory is literally the air in the room.

The fourth significant intervention came after the operation was over. Asilian and colleagues tested an oral wound-healing supplement containing bromelain, Centella asiatica, hyaluronan, vitamin C, zinc, and copper in a randomized, double-blinded, placebo-controlled trial. Patients receiving the supplementation showed significantly improved wound healing on the Early Healing Score and, critically, significantly higher satisfaction at two weeks on a visual analog scale, 9.08 versus 7.42 at p less than 0.001, the largest direct satisfaction effect in the entire review. The authors urge caution, however, noting that the small sample size and short follow-up duration mean this result requires confirmation in larger trials before it changes clinical practice.

Just as instructive are the interventions that failed to lift satisfaction scores but proved valuable in other ways. Educational videos, whether watched at home or integrated into the informed consent process, did not improve satisfaction across three randomized trials, yet patients consistently rated the content as informative and recommended it for future patients, suggesting value in preparedness even when the metric being tracked remained flat. Preoperative phone calls similarly showed no satisfaction benefit in two trials. Intraoperative anxiolytics told an interesting story: in a seven-armed randomized trial comparing lorazepam, diazepam, alprazolam, gabapentin, pregabalin, melatonin, and placebo, single-dose benzodiazepines and GABA-agonist medications proved safe and effective for reducing perioperative anxiety, even though satisfaction scores were uniformly high in every arm. A separate trial found significant within-group anxiety reduction with midazolam at p equal to 0.002, an effect absent in the placebo arm. Anxiety and satisfaction, the review makes clear, are related but distinct constructs that warrant independent measurement.

Other null results carried their own lessons. Handholding and stress balls made no difference to satisfaction or anxiety. Intravenous anesthesia was associated with significantly higher postoperative anxiety than local anesthesia, though possibly confounded by larger defect sizes. Postoperative telephone follow-up did not raise satisfaction, but same-night calls proved most effective at identifying active pain, offering a practical surveillance tool for early complication detection. A film-forming silicone gel dressing improved objective wound healing significantly without increasing contact dermatitis rates compared with triple antibiotic ointment, yet produced no corresponding satisfaction gain, a striking dissociation between clinical outcomes and what patients actually report feeling. Even surgical technique mattered less than expected for overall satisfaction, though melolabial island flap reconstruction yielded better donor site scar satisfaction than the paramedian forehead flap at p equal to 0.026.

The review’s authors are candid about the limitations constraining their conclusions. The analysis relied on a single database, PubMed, and was not prospectively registered, limiting methodological transparency. Only English-language publications were included, introducing language bias, and publication and outcome reporting biases may have underrepresented null results. The predominance of small, single-center randomized trials with heterogeneous instruments and bundled intervention designs makes it difficult to attribute effects to individual components. Their prescription for the field is clear: adequately powered, multicenter trials that isolate individual interventions, incorporate anxiety and preparedness as co-primary outcomes, employ standardized validated instruments, and account for demographic risk factors such as female sex, age of 65 or younger, and smoking, which are associated with worse scar-related outcomes. For now, the message for surgeons is refreshingly practical: hand patients a printed model of their own anatomy, let them look at the defect before you fix it, clear the smoke from the air, and the awake patient on your table may remember the operation far more fondly.

Subject of Research: Perioperative interventions and patient satisfaction in Mohs micrographic surgery for skin cancer

Article Title: Patient-centered perioperative interventions for mohs micrographic surgery: a systematic review

Article References: Patient-centered perioperative interventions for mohs micrographic surgery: a systematic review. (n.d.). https://doi.org/10.1007/s00403-026-04972-2

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04972-2

Keywords: Mohs micrographic surgery, patient satisfaction, systematic review, skin cancer, perioperative care, 3D printed models, smoke evacuation, wound healing, patient-reported outcomes, dermatologic surgery, anxiety reduction, surgical education

The study, published in Breast Cancer Research and Treatment, retrospectively analyzed 669 patients who underwent mastectomy at Shinshu University Hospital between January 2015 and December 2022. Because 20 of those patients had synchronous bilateral disease and were operated on both sides, the analysis covered a total of 709 breasts. Post-surgical bleeding, defined in the study as hemorrhage requiring manual compression or more than 100 milliliters of bloody discharge from a surgical drain by the morning of the first postoperative day, occurred in 42 cases, or 5.9 percent of the cohort. That figure may sound modest, but bleeding after mastectomy is clinically consequential: it can force blood transfusion or reoperation, prolong hospitalization, and delay adjuvant treatment.

What makes the new work distinctive is its focus on a regional rather than a systemic measure of body composition. Surgeons have long known that a high body mass index raises the odds of wound complications, infections, and bleeding after mastectomy, but BMI is a blunt instrument. It cannot distinguish a patient whose weight comes from abundant subcutaneous fat from one carrying substantial lean muscle. Meanwhile, surgical oncology research has increasingly implicated sarcopenia, the loss of skeletal muscle mass, in poor postoperative outcomes across many solid tumors. The standard tool for quantifying muscle in these studies is the skeletal muscle index, calculated from the cross-sectional muscle area at the third lumbar vertebral level on abdominal CT, normalized to height squared.

The Japanese team saw two problems with applying that abdominal measure to breast surgery. First, patients with early-stage breast cancer rarely undergo abdominal CT, so the necessary images often simply do not exist. Second, and more fundamentally, bleeding after mastectomy does not usually start in the abdomen. It originates from small vessels in the subcutaneous tissue or on the surface of the pectoralis major muscle, the very structures exposed during the operation. A global index of trunk musculature may therefore miss the local tissue characteristics that actually determine whether those fragile vessels hold or bleed. Chest CT, by contrast, is routinely obtained for staging in breast cancer, and the pectoralis major is clearly visualized on it.

To exploit that opportunity, the researchers measured the pectoralis major muscle area on axial CT slices at the level of the second thoracic vertebra, using semiautomated delineation within attenuation thresholds of minus 29 to 150 Hounsfield units. The area, expressed in square centimeters, was divided by the patient’s height squared to yield a pectoralis major muscle index, or PMI. Two investigators performed the image analysis while blinded to all postoperative outcomes, and cutoff values for BMI and PMI were derived from receiver operating characteristic curve analysis. The resulting thresholds were 23.7 for BMI and 2.90 for PMI.

The statistical signal was striking. Patients who bled had a significantly higher mean BMI than those who did not, 26.1 versus 22.8, and a significantly lower mean PMI, 2.76 versus 3.12. Yet BMI and PMI were only weakly correlated, with a Pearson coefficient of 0.16, and PMI also correlated only weakly with the conventional lumbar skeletal muscle index. In other words, the chest muscle measurement captures information about body composition that neither BMI nor the standard systemic muscle index reflects. On multivariate logistic regression, high BMI and low PMI each remained independently associated with bleeding, alongside the type of axillary procedure performed. Patients with a high BMI and low PMI had the highest incidence of bleeding at 20.1 percent, compared with 7.4 percent for high BMI with high PMI, 4.8 percent for low BMI with low PMI, and just 1.3 percent for low BMI with high PMI.

The authors offer a mechanistic explanation rooted in surgical anatomy. In patients with a high BMI, abundant subcutaneous fat can obscure small vessels and hinder meticulous hemostasis, raising the chance that a vessel is inadequately sealed and later bleeds. In patients with a low PMI, the pectoralis major itself tends to be atrophic, which may increase the fragility of the vessels running across its surface. Excess fat and diminished local muscle thus act synergistically: the fat makes vessels harder to secure, while the wasted muscle beneath makes them more vulnerable in the first place. Notably, the team’s earlier work found that the lumbar skeletal muscle index predicted bleeding only when normalized to BMI, a pattern consistent with sarcopenic obesity, whereas the regional PMI predicted bleeding on its own, without any adjustment.

One counterintuitive finding deserves mention. Faculty surgeons, defined as board-certified specialists, accounted for a significantly higher share of the bleeding cases than residents, 59.5 percent versus 42.2 percent. The authors argue this likely reflects case allocation rather than skill: faculty were more often assigned technically demanding or high-BMI patients, and at Shinshu every resident-performed mastectomy is directly supervised by a faculty surgeon acting as first assistant. Mastectomy is also a highly standardized procedure with routine drain placement and postoperative compression protocols, which may flatten differences attributable to individual technique. In routine practice, the study suggests, patient-related factors such as BMI and PMI matter more than operator-related ones.

The study has limitations the authors themselves acknowledge. It was retrospective and conducted at a single institution, the number of bleeding events was relatively small, and the bleeding definition captured early postoperative events rather than minor or late-onset ones. Bilateral cases were analyzed as independent observations, although sensitivity analyses excluding them produced essentially unchanged results. The BMI and PMI cutoffs were derived from the same cohort they were tested on, and the population was exclusively Japanese, so external validation in larger, more diverse cohorts will be needed before the thresholds can be generalized.

Even so, the practical implication is appealingly simple. Most breast cancer patients already have a preoperative chest CT, and measuring one muscle on an existing scan adds no cost, radiation, or delay. If validated prospectively, the pectoralis major muscle index could become a routine element of perioperative risk stratification, flagging patients, particularly those with both high BMI and low PMI, who warrant especially careful intraoperative hemostasis, closer drain monitoring, and a lower threshold for early intervention. In an era when body composition is increasingly recognized as a modifiable factor in cancer care, the study adds a new twist: for mastectomy outcomes, the muscle that matters most may be the one directly under the surgeon’s hands.

Subject of Research: Pectoralis major muscle mass as a predictor of post-surgical bleeding after mastectomy in breast cancer patients

Article Title: Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer

Article References: Iji, R., Oba, T., Miyazawa, R., Kitazawa, A., Kiyosawa, N., Katsuyama, S., Morikawa, H., Amitani, M., Chino, T., Shimizu, T., Ono, M., Natori, K., Kanai, T., & Ito, K.-I. (2026). Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer. Breast Cancer Research and Treatment, 219(1), Article 2. https://doi.org/10.1007/s10549-026-08063-8

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08063-8

Keywords: breast cancer, mastectomy, pectoralis major muscle index, post-surgical bleeding, body mass index, body composition, sarcopenia, computed tomography, surgical complications, risk stratification, perioperative care, Shinshu University

The study, conducted by İsmail Aşatır and Atiye Erbaş of Duzce University’s Department of Surgical Nursing, enrolled 122 patients at the orthopedic clinic of a tertiary university hospital between November 2023 and February 2024. Participants were randomly assigned in equal numbers to an intervention group and a control group, with 61 patients in each arm. Those in the intervention group received a structured preoperative pain education program delivered by nurses, while the control group received the standard care normally provided at the clinic. The trial was prospectively registered with ClinicalTrials.gov under identifier NCT06104254 on 23 October 2023, before participant enrollment began, a detail that strengthens confidence in the integrity of the randomization protocol.

The researchers tracked two primary outcomes: the intensity of pain patients reported after surgery, measured on the Numeric Rating Scale, and the patients’ pain beliefs, assessed with the Pain Beliefs Scale. The Pain Beliefs Scale distinguishes between two fundamentally different ways of thinking about pain. Psychological pain beliefs frame pain as something influenced by thoughts, emotions, and mental states, whereas organic pain beliefs attribute pain entirely to physical injury and tissue damage. This distinction matters because a growing body of pain science suggests that patients who understand pain as modifiable, rather than as a pure readout of bodily harm, tend to cope better and report less severe pain.

To analyze their data, the team used linear mixed-effects models, a statistical approach well suited to repeated measurements collected over time. Rather than comparing groups only at a single moment, mixed-effects models can capture how outcomes evolve across multiple postoperative time points and can test whether the two groups followed different trajectories. The key quantity in such analyses is the group-by-time interaction, which asks whether the change over time in one group differs statistically from the change over time in the other. A significant interaction is the signature of diverging paths, not merely a difference in a snapshot.

That is precisely what the researchers found for postoperative pain intensity. The linear mixed-effects model demonstrated a significant group-by-time interaction, indicating that pain followed genuinely different trajectories in the intervention and control groups. In practical terms, patients who had received structured preoperative pain education from nurses experienced a more favorable course of postoperative pain than those who received standard care alone. For a field in which postoperative pain management still relies heavily on escalating analgesic regimens, the idea that a conversation before surgery can bend the pain curve is striking.

The effects on pain beliefs were more nuanced. The analysis revealed a significant group-by-time interaction for psychological pain beliefs, meaning the education program produced measurable shifts in how patients conceptualized the psychological dimension of pain. Patients who had been educated came to view pain as something their thoughts and coping strategies could influence, a reframing that aligns with modern biopsychosocial models of pain. However, no significant intervention effect was found for organic pain beliefs. In other words, the program successfully updated patients’ understanding of the psychological side of pain but did not alter their conviction that pain fundamentally originates in physical injury, which the researchers suggest may be a more entrenched belief to shift.

The trial also examined several secondary factors. Pain intensity tended to be higher among women and among patients who reported fear of pain before their operations, although these differences did not reach statistical significance in the analysis. The directional pattern is nonetheless consistent with a wider literature linking preoperative pain catastrophizing and anxiety to worse postoperative outcomes, and it hints that patients who arrive frightened may be precisely those who benefit most from reassurance and preparation. Larger trials would be needed to determine whether these subgroup patterns are real effects or statistical noise.

What makes the findings compelling is the simplicity of the intervention relative to its reach. Preoperative education requires no new drugs, no additional hardware, and no change to surgical technique. It asks nurses to spend time before surgery explaining what patients should expect, how pain can be managed, and what role their own beliefs and behaviors play in recovery. Orthopedic wards are staffed by nurses who already interact with patients in the preoperative window, so embedding structured pain education into that existing contact represents a marginal cost for a potentially substantial gain in patient comfort, mobility, and possibly even length of stay.

The authors conclude that preoperative nursing education was associated with reduced postoperative pain intensity and favorable changes in psychological pain beliefs, though not in organic pain beliefs, and they suggest that structured preoperative pain education be considered as part of routine perioperative nursing care to improve postoperative pain management. The research received no specific grant from any funding agency and was approved by the Ethics Committee of the Faculty of Medicine at Duzce University, with the trial conducted in accordance with the Declaration of Helsinki.

Limitations and open questions remain. The study was conducted at a single tertiary center in one country, and the generalizability of the effect to other health systems, surgical populations, and cultural contexts will need to be tested. The incomplete shift in organic beliefs suggests that education programs might be strengthened by directly addressing the intuitive but incomplete equation of pain with tissue damage. Still, the trial adds to mounting evidence that the mind’s framing of pain is not a passive bystander in recovery. As health systems search for affordable ways to improve surgical outcomes, this study suggests one of the most powerful tools available may be a well-informed nurse and a few crucial minutes before the operation begins.

Subject of Research: Effect of preoperative nurse-led pain education on postoperative pain and pain beliefs in orthopedic surgical patients

Article Title: The effect of preoperative nursing education on postoperative pain intensity and pain beliefs in orthopedic surgical patients: randomized controlled trial

Article References: The effect of preoperative nursing education on postoperative pain intensity and pain beliefs in orthopedic surgical patients: randomized controlled trial. (n.d.). https://doi.org/10.1186/s12912-026-05422-0

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05422-0

Keywords: preoperative education, postoperative pain, orthopedic surgery, pain beliefs, nursing, randomized controlled trial, pain management, pain intensity, perioperative care, Turkey, BMC Nursing, biopsychosocial model