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Glucagon-like peptide-1 (GLP-1) receptor agonists have transformed the therapeutic landscape for type 2 diabetes mellitus (T2DM) and obesity. These agents mimic endogenous GLP-1, which enhances glucose-dependent insulin secretion, delays gastric emptying, and promotes satiety. Initially evaluated in randomized controlled trials (RCTs), GLP-1 RAs have demonstrated significant efficacy in improving glycemic control and reducing weight. However, RCTs often fail to capture the heterogeneity of real-world clinical populations. Therefore, real-world data is essential for evaluating the broader clinical utility, comparative effectiveness, and safety of GLP-1 agonists across different patient demographics and comorbidity profiles.

A comprehensive study by Thomsen et al. used nationwide registries to evaluate real-world outcomes associated with GLP-1 agonists, particularly with newer agents such as semaglutide and liraglutide. Their analysis revealed consistent weight loss and glycemic improvement across various subgroups, including individuals with significant comorbid conditions, such as cardiovascular disease or renal impairment (1).

Real-world data suggest that GLP-1 agonists may offer advantages over traditional therapies, such as basal insulin. In another study, Yang et al. analyzed the cost-effectiveness and clinical outcomes of GLP-1 agonists versus insulin using population-level datasets. Their findings revealed that GLP-1 agonists not only resulted in similar or superior glycemic control but also significantly reduced body weight and the risk of hypoglycemia (2).

Safety is an important concern in long-term pharmacotherapy. Gastrointestinal (GI) adverse events are the most commonly reported side effect associated with GLP-1 receptor agonist use. Liu et al. analyzed real-world data from the FDA Adverse Event Reporting System (FAERS) to compare the incidence of GI events among different GLP-1 receptor agonists. They found that semaglutide was associated with a higher incidence of nausea and vomiting, while exenatide was associated with a higher incidence of diarrhea. Despite these associations, the events were largely self-limiting and rarely led to treatment discontinuation, particularly when slow dose escalation protocols were employed (3).

Tumor-related adverse effects are a more serious but less frequent safety concern. Yang et al. analyzed FAERS data spanning nearly two decades to investigate potential oncogenic risks associated with GLP-1 agonist therapy. The study identified a small number of reports indicating possible associations with medullary thyroid carcinoma and pancreatic neoplasms. However, the authors cautioned that these findings were based on spontaneous reporting systems and did not establish causality. They emphasized the need for continued surveillance and mechanistic studies to clarify any potential biological links (4).

Renal and cardiovascular outcomes also merit consideration when evaluating GLP-1 agonists in the real world. In a meta-analysis of observational studies, Caruso et al. reported favorable renal outcomes among GLP-1 agonist users, including slower progression of albuminuria and a reduced incidence of acute kidney injury, compared to other glucose-lowering drugs. Cardiovascular outcomes also trended positively, consistent with randomized controlled trial (RCT) findings, such as those from the LEADER and SUSTAIN-6 trials. However, the authors noted the need for longer follow-up periods and stratification by baseline renal function and cardiovascular risk to validate these findings in the general population.

In conclusion, the growing body of real-world evidence confirms that GLP-1 agonists effectively improve glycemic control and promote weight loss and are generally safe when used in appropriate populations. Their comparative advantage over insulin and other antidiabetic agents makes them an appealing choice in many clinical scenarios. Nevertheless, careful attention to adverse event profiles, particularly GI symptoms and potential tumor risks, is warranted. As their use continues to expand, real-world studies will remain indispensable in refining clinical guidelines and optimizing patient outcomes.

References

1. Thomsen RW, Mailhac A, Løhde JB, Pottegård A. Real-world evidence on the utilization, clinical and comparative effectiveness, and adverse effects of newer GLP-1RA-based weight-loss therapies. Diabetes Obes Metab. 2025;27 Suppl 2(Suppl 2):66-88. doi:10.1111/dom.16364
2. Yang CY, Chen YR, Ou HT, Kuo S. Cost-effectiveness of GLP-1 receptor agonists versus insulin for the treatment of type 2 diabetes: a real-world study and systematic review. Cardiovasc Diabetol. 2021;20(1):21. Published 2021 Jan 19. doi:10.1186/s12933-020-01211-4
3. Liu L, Chen J, Wang L, Chen C, Chen L. Association between different GLP-1 receptor agonists and gastrointestinal adverse reactions: A real-world disproportionality study based on FDA adverse event reporting system database. Front Endocrinol (Lausanne). 2022;13:1043789. Published 2022 Dec 7. doi:10.3389/fendo.2022.1043789
4. Yang Z, Lv Y, Yu M, et al. GLP-1 receptor agonist-associated tumor adverse events: A real-world study from 2004 to 2021 based on FAERS. Front Pharmacol. 2022;13:925377. Published 2022 Oct 25. doi:10.3389/fphar.2022.925377
5. Caruso I, Cignarelli A, Sorice GP, et al. Cardiovascular and Renal Effectiveness of GLP-1 Receptor Agonists vs. Other Glucose-Lowering Drugs in Type 2 Diabetes: A Systematic Review and Meta-Analysis of Real-World Studies. Metabolites. 2022;12(2):183. Published 2022 Feb 15. doi:10.3390/metabo12020183

Intravenous (IV) access is essential in anesthesia and surgery for rapid and reliable administration of fluids and medications. While upper extremity veins are preferred due to lower complication rates and easier access, there are situations (such as trauma, burns, or inaccessible upper extremity veins) where IV access in the lower extremities is required to proceed with anesthesia and surgery.

The most common lower extremity sites for peripheral IV access are the great saphenous vein at the ankle and the lesser saphenous vein, chosen for their superficial locations and consistent anatomy. In emergency or critical care situations, the femoral vein is preferred for central venous access because it is large, easy to identify, and suitable for rapid infusion. However, IV access in the lower extremities carries unique risks, particularly a higher incidence of complications such as thrombophlebitis, deep vein thrombosis (DVT), and catheter-related infections compared to upper extremity sites. These risks are amplified in adults due to factors such as slower blood flow, increased limb dependence, and a higher prevalence of peripheral vascular disease. Because of these concerns, guidelines consistently recommend limiting the duration of lower extremity IV access and transitioning to upper extremity access as soon as possible (1).

Recent advances in ultrasound technology have significantly improved the safety and success rates of acquiring IV access in the lower extremities, making ultrasound an increasingly useful tool for anesthesia and surgery. Ultrasound guidance provides direct visualization of veins, which not only facilitates cannulation in patients with difficult vascular access but also reduces the risk of complications such as arterial puncture or multiple failed attempts. Several studies support the use of ultrasound for both peripheral and femoral vein cannulation, showing improvements in first-pass success rates and reductions in procedure-related complications (1). This is particularly relevant for central access via the femoral vein, which, while easy to access, is associated with higher rates of infection and thrombotic events compared to central access via the subclavian or internal jugular vein. In a landmark study, Merrer et al. found that femoral catheterization had higher rates of both infection and thrombosis than subclavian access, reinforcing the recommendation that femoral sites should be reserved for specific clinical situations or emergencies (2).

IV access in the lower extremities is generally considered safer and more feasible in pediatric patients than in adults because children have fewer vascular comorbidities and their veins are less prone to thrombosis. However, complications such as infiltration, infection, and phlebitis still occur and require regular evaluation and prompt intervention if problems arise (3). In adult patients, early removal and routine monitoring are essential strategies to reduce complications, especially in those with risk factors for thrombosis or infection.

To minimize risk, several key practices are recommended: use of ultrasound guidance, strict aseptic technique during insertion, regular inspection of the IV site, and prompt removal of lower extremity catheters when no longer needed. Providers should monitor for signs of DVT, such as swelling, pain, and erythema, as well as for local or systemic infection. In addition, when femoral access is required for central venous catheterization, careful attention to catheter care protocols and early transition to safer sites are critical to reducing adverse outcomes (4).

Although lower extremity IV access is sometimes unavoidable in anesthesia and surgery, its use is associated with increased risks. Modern techniques such as ultrasound have improved the safety profile of these procedures, but clinicians must remain vigilant for potential complications and limit the use of lower extremity access when possible. With careful management, lower extremity IV access can be a safe and effective option for patients with limited alternatives.

References

1. Witting MD. IV access difficulty: incidence and delays in an urban emergency department. J Emerg Med. 2012;42(4):483-487. doi:10.1016/j.jemermed.2011.07.030
2. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286(6):700-707. doi:10.1001/jama.286.6.700
3. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601-1606. doi:10.1056/NEJM199412153312401
4. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7. doi:10.1016/j.ajem.2008.09.001

Three-dimensional (3D) printing, also known as additive manufacturing, has significantly impacted the surgical field by enabling the creation of patient-specific models, implants, and instruments that enhance surgical precision and outcomes. These advancements enable more precise pre-surgical planning and personalized interventions, transforming how clinicians operate in the OR (Hoang et al., 2016).

Among its most impactful applications, 3D-printed anatomical models have been widely used in pre-surgical planning, particularly for complex procedures. Nearly every part of the human body has been replicated, providing surgeons with valuable tools for study and rehearsal before performing procedures (Ballard et al., 2018; Hoang et al., 2016). Traditionally, surgeons have relied on two-dimensional (2D) imaging and their clinical experience to plan operations. However, converting imaging data into a 3D model offers a more intuitive and comprehensive understanding of patient-specific anatomy (Ballard et al., 2018). Using 3D printing, lifelike models are created to enable surgeons to visualize and even rehearse surgical interventions, often leading to improved strategies and reduced surprises in the OR. Empirical studies have consistently demonstrated that integrating 3D models into surgical planning enhances outcomes, with reports showing improved accuracy and reduced operative times (Tack et al., 2016).

The efficiency of surgical procedures is notably increased when surgeons prepare using patient-specific models. In orthopedic trauma cases, research found that implementing 3D-printed models reduced average operative time by approximately 20% and decreased intraoperative blood loss by 25% compared to conventional planning methods (Morgan et al., 2020). Furthermore, a recent cost analysis indicated that using 3D-printed anatomical models saved 62 minutes of operating room time per case, equating to approximately $3,700 in cost savings per surgery (Ballard et al., 2020). These time savings not only enhance efficiency but also diminish the duration patients spend under anesthesia, improving patient safety. Additionally, 3D models are effective tools for patient education, offering a tangible representation of the relevant anatomy and the planned procedure (Ballard et al., 2018).​

3D printing technology also enables the design and fabrication of implants tailored precisely to an individual’s anatomical and pathological characteristics. Traditionally, surgeons have been constrained to using standard implants in limited sizes, which may not perfectly fit every patient’s unique anatomy. A prominent example is observed in craniofacial surgery, where computed tomography (CT) scans of a skull defect can be utilized to create a titanium implant that accurately restores the patient’s original skull contour (Martelli et al., 2016). Such personalized implants have been employed in complex reconstructions involving the head, spine, and limbs, particularly in cases where standard implants proved inadequate (Kadakia et al., 2020). In scenarios such as orthopedic oncology or severe trauma, 3D printing facilitates the replacement of substantial bone segments with implants that conform precisely to the patient’s unique geometry, thereby potentially enhancing functional outcomes and reducing the chance that the patient will need to return to the OR for further correction. Preliminary clinical reports are promising, indicating that custom implants have enabled limb-sparing surgeries and anatomically precise joint replacements that would have been challenging or unfeasible with conventional implants (Kadakia et al., 2020).​

3D printing has become a transformative tool in the modern OR, offering unparalleled precision, customization, and efficiency. This technology enhances preoperative planning, reduces intraoperative risks, and improves surgical outcomes across multiple specialties by enabling the creation of patient-specific anatomical models, implants, and surgical guides. Challenges such as cost, regulatory considerations, and material limitations remain, but ongoing advancements in biocompatible materials, faster printing techniques, and regulatory frameworks will likely facilitate broader clinical adoption. As technology continues to evolve, 3D printing is poised to revolutionize surgery further, paving the way for increasingly personalized and efficient medical interventions.

References

1. Ballard, D. H., Trace, A. P., Ali, S., Hodgdon, T., Zygmont, M. E., DeBenedectis, C. M., & Lenchik, L. (2018). Clinical applications of 3D printing: Primer for radiologists. Academic Radiology, 25(1), 52–65. https://doi.org/10.1016/j.acra.2017.08.004
2. Ballard, D. H., Mills, P., Duszak, R. Jr., Weisman, J. A., Rybicki, F. J., & Woodard, P. K. (2020). Medical 3D printing cost-savings in orthopedic and maxillofacial surgery: Cost analysis of operating room time saved with 3D printed anatomic models and surgical guides. Academic Radiology, 27(8), 1103–1113. https://doi.org/10.1016/j.acra.2020.02.012
3. Hajnal, B., Pokorni, A. J., Turbucz, M., Bereczki, F., Bartos, M., Lazáry, Á., & Eltes, P. E. (2025). Clinical applications of 3D printing in spine surgery: A systematic review. European Spine Journal, 34(2), 454–471. https://doi.org/10.1007/s00586-025-07241-9
4. Hoang, D., Perrault, D., Stevanovic, M., & Ghiassi, A. (2016). Surgical applications of three-dimensional printing: A review of current literature & how to get started. Annals of Translational Medicine, 4(23), 456. https://doi.org/10.21037/atm.2016.12.18
5. Kadakia, R. J., Wixted, C. M., Allen, N. B., Hanselman, A. E., & Adams, S. B. (2020). Clinical applications of custom 3D-printed implants in complex lower extremity reconstruction. 3D Printing in Medicine, 6(1), 29. https://doi.org/10.1186/s41205-020-00075-2
6. Martelli, N., Serrano, C., van den Brink, H., Pineau, J., Prognon, P., Borget, I., & El Batti, S. (2016). Advantages and disadvantages of three-dimensional printing in surgery: A systematic review. Surgery, 159(6), 1485–1500. https://doi.org/10.1016/j.surg.2015.12.017
7. Morgan, C., Khatri, C., Hanna, S. A., Ashrafian, H., & Sarraf, K. M. (2020). Use of three-dimensional printing in preoperative planning in orthopedic trauma surgery: A systematic review and meta-analysis. World Journal of Orthopaedics, 11(1), 57–66. https://doi.org/10.5312/wjo.v11.i1.57
8. Tack, P., Victor, J., Gemmel, P., & Annemans, L. (2016). 3D-printing techniques in a medical setting: A systematic literature review. BioMedical Engineering OnLine, 15(1), 115. https://doi.org/10.1186/s12938-016-0236-4

The preparation of a patient’s skin before surgery is a critical step in reducing the risk of surgical site infections (SSIs), which are among the most common postoperative complications. When combined with sterile techniques, proper skin preparation helps to minimize the microbial load on the skin, thereby preventing pathogens from entering the surgical site. SSIs can lead to increased healthcare costs, prolonged hospital stays, and significant patient morbidity. Sterile technique—encompassing practices such as hand hygiene, sterile draping, and appropriate antiseptic application—is essential in maintaining a controlled environment free of harmful microorganisms. Preoperative skin preparation is particularly important as it aims to remove transient microorganisms and reduce resident flora to levels that are no longer pathogenic.

There are various protocols available for preoperative patient skin preparation, and the appropriate selection depends on factors such as the surgical site, patient sensitivities, and type of procedure. Two commonly used protocols are chlorhexidine-alcohol and povidone-iodine solutions. Chlorhexidine-alcohol, a combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol, is widely recommended due to its broad-spectrum antimicrobial activity and prolonged residual effect. It is effective against both gram-positive and gram-negative bacteria, making it suitable for a wide range of surgeries. Povidone-iodine is another widely used antiseptic, particularly for patients sensitive to chlorhexidine or for procedures near mucous membranes. It offers broad antimicrobial coverage but has a shorter residual effect compared to chlorhexidine. Preoperative protocols may also include patient cleansing with chlorhexidine-based wipes or solutions at home before surgery, further reducing microbial load on the skin.

The step-by-step technique for surgical skin preparation involves a systematic approach to ensure thorough antisepsis of the surgical site. First, the healthcare provider assesses the patient and surgical site to select the appropriate antiseptic solution. They then don sterile gloves to maintain aseptic technique throughout the process. The prep begins at the planned incision site and moves outward in an ever-widening circular motion, covering an area larger than the anticipated surgical field. For alcohol-based solutions, the skin is gently wiped following the manufacturer’s instructions, typically using a back-and-forth motion for the prescribed time based on the body location. It’s crucial to allow the solution adequate drying time, which can range from three minutes on hairless skin to up to an hour in hair for alcohol-based products. Once dry, sterile drapes are applied to isolate the prepped area. For procedures involving multiple sites, such as grafts or abdominal-perineal surgeries, separate prep set-ups are used for each area to prevent cross-contamination. Throughout the process, care is taken to avoid touching non-sterile items and to prevent the accumulation of prep solution, which could lead to chemical burns. After patient skin preparation is complete, the surgical team maintains vigilance to ensure the sterile field remains intact until the wound is sealed and dressed.

The effectiveness of these disinfectants is due to their mechanisms of action. Chlorhexidine disrupts bacterial cell membranes, causing leakage of cellular contents and leading to cell death. It is highly effective against gram-positive bacteria like Staphylococcus aureus and gram-negative bacteria like Escherichia coli, though it has limited efficacy against fungi and viruses. Alcohol, often used in combination with other agents, works by denaturing proteins and rapidly killing microorganisms upon contact. Povidone-iodine penetrates microbial cell walls and disrupts metabolic pathways, making it effective against a wide range of bacteria, fungi, and some viruses.

Evidence from clinical studies highlights the importance of selecting appropriate skin prep solutions to reduce SSIs. For example, a systematic review found that 2–2.5% chlorhexidine in alcohol significantly reduced SSI rates compared to aqueous iodine solutions (relative risk 0.75). Another study demonstrated that chlorhexidine-alcohol outperformed povidone-iodine in bacterial eradication during foot and ankle surgeries. These findings underscore the importance of evidence-based practices when choosing antiseptic agents for preoperative skin preparation. By tailoring protocols to specific needs—such as anatomical location or patient sensitivities—healthcare providers can optimize outcomes and reduce the risk of SSIs.

In conclusion, patient skin preparation protocols are a cornerstone of infection prevention in surgical settings. Adherence to sterile techniques and the use of effective disinfectants tailored to individual circumstances can significantly lower the incidence of SSIs. As research continues to refine these protocols, healthcare providers have more evidence-based tools at their disposal to ensure safer surgical outcomes.

References

1. AORN Outpatient Surgery Magazine. The Essentials: Peerless Skin Prep: Here’s How. July 2023. DOI: https://www.aorn.org/outpatient-surgery/article/the-essentials-peerless-skin-prep-here-s-how
2. American Academy of Orthopaedic Surgeons (AAOS). Surgical Site Preparation Toolkit. Accessed February 2025. DOI: https://www.aaos.org/quality/quality-programs/quality-toolkits/surgical-site-preparation/
3. Outpatient Surgery Magazine. Your Updated Guide to Surgical Skin Preps. November 2022. DOI: https://www.aorn.org/outpatient-surgery/article/2010-May-your-updated-guide-to-surgical-skin-preps
4. PubMed Central (PMC). A Systematic Review on Skin Preparation Solutions for SSI Prevention. August 2022. DOI: https://pubmed.ncbi.nlm.nih.gov/35985350/
5. Centers for Disease Control and Prevention (CDC). Chemical Disinfectants. November 2023. DOI: https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/chemical-disinfectants.html

Healthcare disparities in the perioperative period—including the preoperative, intraoperative, and postoperative phases—are often overlooked, despite their significant impact on patient outcomes. There are many socioeconomic factors impacting surgical access, quality of care, and patient outcomes. One important factor is language barriers. Approximately 22% of the U.S. population speak a language other than English at home, and limited English proficiency is linked to poorer healthcare access, an increased risk of adverse advents, worse patient care experiences, reduced understanding of medical instructions, and worse overall health outcomes, in both in-patient and out-patient settings.¹ Navigating language barriers with patients is an essential skill for anesthesiologists.

Even with interpretation services, limited English proficiency can affect the informed consent process, patient comprehension of perioperative instructions, and more. Many patients with limited English proficiency describe the process of finding and working with an interpreter as an uphill battle, with common feelings of betrayal and frustration regarding their healthcare experience.² Patients can experience specific difficulties in the realm of anesthesia, especially regarding pain management. Communication barriers can lead to the misinterpretation of a patient’s pain level, an inadequate delivery of pain relief, or an inability to effectively induce anesthesia or analgesia, which can affect patient recovery, increase the risk of postoperative complications, and diminish patient satisfaction. As such, a comprehensive review of how language barriers impact anesthesia can guide large-scale efforts aimed at improving how anesthesiologists approach care for more vulnerable patients.³

Research on the impact of language barriers in obstetric anesthesia has found that Spanish-speaking women were significantly less likely to anticipate and use neuraxial anesthesia compared to English-speaking women, and these disparities persist even after adjusting for age, marital status, income, obstetric provider type (obstetrician or midwife), and labor type.⁴ One randomized controlled trial demonstrated increased use of labor epidurals by Latinx beneficiaries after the establishment of an education program. These findings suggest social determinants such as language barriers must be evaluated thoroughly to fully address health disparities.⁴

In a prospective survey study conducted at Harvard Medical Center, separate surveys were sent to the Department of Interpretation Services (DIS) and the Department of Anesthesia (DA). The questions sent to DIS staff explored the different languages spoken and the relative experiences of the interpreters, along with their level of training and understanding of anesthesia-specific procedures and concepts. The battery of questions sent to DA anesthesiologists and nurses inquired about their past experiences with interpreters and situations that led to ineffective communication due to language barriers. After the survey period closed, results showed 97% of DIS staff did not have anesthesia-specific training.⁵ Only 54% of respondents felt they were given adequate training regarding anesthesia consent, and only 25% reported complete understanding and comfort with consent for common invasive monitoring, such as central lines and arterial lines. Despite these numbers, the respondents reported feeling confident consenting for anesthesia on behalf of their patients, including for general, neuraxial, and regional anesthesia. 58% of DA providers felt unsure their interpreters had sufficient training regarding anesthesia consent. Most DA staff were comfortable with the interpretation of neuraxial or regional anesthesia but reported difficulty explaining the difference between monitored anesthesia care and general anesthesia. The study identified increasing interpreters’ level of anesthesia-specific training as an important step to help anesthesiologists and patients navigate language barriers.⁵  

Efficiently addressing healthcare disparities in the perioperative period, particularly those linked to language barriers, is critical for improving patient outcomes. Limited English proficiency poses significant challenges in communication, especially in informed consent and pain management, which can directly affect the quality of anesthesia and recovery. The evidence underscores the importance of targeted interventions, such as increasing the training of interpreters in anesthesia-related concepts and improving access to culturally competent care.

References

1. Divi, Chandrika, et al. “Language Proficiency and Adverse Events in US Hospitals: A Pilot Study.” International Journal for Quality in Health Care, vol. 19, no. 2, Apr. 2007, pp. 60–67. https://doi.org/10.1093/intqhc/mzl069
2. Steinberg, Emma M., et al. “The ‘Battle’ of Managing Language Barriers in Health Care.” Clinical Pediatrics, vol. 55, no. 14, Dec. 2016, pp. 1318–27. https://doi.org/10.1177/0009922816629760
3. Joo, Hyundeok, et al. “Association of Language Barriers With Perioperative and Surgical Outcomes: A Systematic Review.” JAMA Network Open, vol. 6, no. 7, July 2023, p. e2322743. https://doi.org/10.1001/jamanetworkopen.2023.22743
4. Ehie, Odinakachukwu, et al. “What Is the Role for Anesthesiologists and Anesthesia Practices in Ensuring Access, Equity, Diversity, and Inclusion?” ASA Monitor, vol. 85, no. S10, Oct. 2021, pp. 45–48. https://doi.org/10.1097/01.ASM.0000795196.13554.35
5. Shapeton, Alexander, et al. “Anesthesia Lost in Translation: Perspective and Comprehension.” The Journal of Education in Perioperative Medicine : JEPM, vol. 19, no. 1, Jan. 2017, p. E505. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327869/

Electronic Health Records (EHR) systems have become a cornerstone of modern healthcare, aiming to improve patient management, streamline operations, and enhance data-driven decision-making. While much attention is often given to EHR adoption in the United States, countries worldwide are developing and implementing their own systems, tailored to local needs, policies, and healthcare structures. EHR systems outside the United States reveal diverse approaches, successes, and challenges, providing valuable insights into global health informatics.

EHR Systems in Europe

The healthcare systems with the greatest adoption of EHR systems are outside the US, with Nordic countries like Denmark, Sweden, and Finland boasting near-universal coverage and interoperability across healthcare providers. Centralized systems make it easy to share patient data between hospitals, clinics, and general practitioners, improving continuity of care. Denmark’s “Sundhed.dk,” a national health portal, allows patients to access their records, book appointments, and communicate with healthcare providers ^1,2.

Despite successes in some places, many European countries face issues with fragmented systems. In Germany and France, a number of structural factors hinder the smooth national implementation of EHR systems. Privacy concerns under the General Data Protection Regulation (GDPR) add complexity to data management and cross-border healthcare initiatives ^3–5.

EHR Systems in Asia

China has rapidly scaled its EHR systems, driven by its National Health Informatization Plan. Large hospitals in urban areas have sophisticated EHRs, enabling efficient management of millions of patient records. However, rural regions lag behind, with limited access to digital healthcare infrastructure. Interoperability remains a challenge in connecting diverse systems across the country ^6–8.

India’s National Digital Health Mission (NDHM) aims to establish a unified digital health system, including an EHR system linked to unique health identifications. However, the initiative faces significant obstacles, including low healthcare digitization in rural areas and varying literacy levels, on top of general concerns about data security and privacy ⁹.

EHR Systems in Africa

Africa’s EHR landscape reflects the continent’s diverse healthcare needs and economic disparities—countries like South Africa and Kenya have adopted EHRs in urban hospitals, while many rural areas rely on paper-based systems or basic digital tools. The lack of infrastructure, unreliable internet access, and funding constraints pose significant challenges to more widespread adoption in many African countries.

Innovative approaches, such as cloud-based EHRs and mobile health solutions, are gaining ground. For example, Kenya’s open-source OpenMRS platform supports EHR implementation in resource-limited settings ^10–12.

EHR Systems in Latin America

Latin American countries are largely seeing gradual adoption of national EHR systems, spurred by governmental efforts and private sector investment. Countries like Brazil and Chile have implemented national health information systems, but uneven adoption persists due to economic disparities and limited interoperability. A notable success story is Uruguay’s Historia Clínica Electrónica Nacional (HCEN), a nationwide EHR system connecting public and private providers—demonstrating how strong government leadership and a collaborative approach can overcome systemic barriers ^13–15.

Global Challenges and Lessons

Both inside and outside the US, one of the most persistent challenges facing the use of EHR systems is achieving interoperability—ensuring that systems can communicate seamlessly across different platforms, facilities, and borders. In addition, data privacy and cybersecurity are universal concerns ^16,17.

References

1.            Hägglund, M. et al. A Nordic Perspective on Patient Online Record Access and the European Health Data Space. J Med Internet Res 26, e49084 (2024). :10.2196/49084

2.         sundhed.dk – Få klare svar om din sundhed. https://www.sundhed.dk/.

3.         General Data Protection Regulation (GDPR) – Legal Text. https://gdpr-info.eu/.

4.            Cuggia, M. & Combes, S. The French Health Data Hub and the German Medical Informatics Initiatives: Two National Projects to Promote Data Sharing in Healthcare. Yearb Med Inform 28, 195–202 (2019). doi: 10.1055/s-0039-1677917

5.            Schmitt, T. Implementing Electronic Health Records in Germany: Lessons (Yet to Be) Learned. International Journal of Integrated Care 23, (2023). doi: 10.5334/ijic.6578

6.         Translation: 14th Five-Year Plan for National Informatization – Dec. 2021. https://digichina.stanford.edu/work/translation-14th-five-year-plan-for-national-informatization-dec-2021/.

7.         Liang, J. et al. Adoption of Electronic Health Records (EHRs) in China During the Past 10 Years: Consecutive Survey Data Analysis and Comparison of Sino-American Challenges and Experiences. J Med Internet Res 23, e24813 (2021). doi: 10.2196/24813.

8.         Li, C. et al. Implementation of National Health Informatization in China: Survey About the Status Quo. JMIR Med Inform 7, e12238 (2019). doi: 10.2196/12238

9.         National Digital Health Mission | Make In India. https://www.makeinindia.com/national-digital-health-mission.

10.       Kenya – OpenMRS Talk. https://talk.openmrs.org/c/local/kenya/35.

11.       Katurura, M. C. & Cilliers, L. Electronic health record system in the public health care sector of South Africa: A systematic literature review. Afr J Prim Health Care Fam Med 10, 1746 (2018). doi: 10.4102/phcfm.v10i1.1746.

12.       Akanbi, M. O. et al. Use of Electronic Health Records in sub-Saharan Africa: Progress and challenges. J Med Trop 14, 1–6 (2012).

13.       Historia Clínica Electrónica Nacional | Agencia de Gobierno Electrónico y Sociedad de la Información y del Conocimiento. https://www.gub.uy/agencia-gobierno-electronico-sociedad-informacion-conocimiento/node/312.

14.       Capurro, D. et al. Chile’s National Center for Health Information Systems: A Public-Private Partnership to Foster Health Care Information Interoperability. Stud Health Technol Inform 245, 693–695 (2017).

15.       Alves, T. F., Almeida, F. A., Brito, F. A., Tourinho, F. S. V. & de Andrade, S. R. Regulation and Use of Health Information Systems in Brazil and Abroad: Integrative Review. Comput Inform Nurs 40, 373–381 (2022). doi: 10.1097/CIN.0000000000000828.

16.       What is EHR Interoperability and why is it important? | HealthIT.gov. https://www.healthit.gov/faq/what-ehr-interoperability-and-why-it-important.

17.       Basil, N. N., Ambe, S., Ekhator, C. & Fonkem, E. Health Records Database and Inherent Security Concerns: A Review of the Literature. Cureus 14, e30168. DOI: 10.7759/cureus.30168

Patient positioning in the perioperative setting is extremely important. While positioning before and during surgery is often discussed, an important aspect of patient care in a procedural setting is patient positioning after surgery and anesthesia. Proper positioning can help prevent various complications such as respiratory distress, circulatory issues, and pressure injuries (Patterson et al., 2024). As anesthesia wears off, patients may experience muscle weakness, shallow breathing, and discomfort. In addition, positioning after surgery and anesthesia must consider the wound site and the risk of nausea and vomiting.

Positioning after surgery and anesthesia can be crucial in patients with postoperative hypoxemia. Postoperative hypoxemia is a condition characterized by low levels of oxygen in the blood. Complications of postoperative hypoxemia include arrhythmias, abnormal blood pressures, and damage to the nervous system (Wang et al., 2024). At the end of a procedure, the supine position is commonly used for extubation. However, in the supine position, the capacity of the lungs is decreased. The semi-recumbent position, where a patient is slightly sitting upwards, is another position that can be used in extubation as it has been shown to increase lung capacity (Wang et al., 2024). In a randomized clinical trial, patients who were positioned in a 30-degree semi-recumbent position during extubation had a lower incidence of hypoxemia (Wang et al., 2024). This may be because diaphragm function improves in the semi-recumbent position compared to the supine position.

Proper circulation after surgery and anesthesia is also an important concern that can be addressed through careful patient positioning. Immobility during and after surgery can increase the risk of blood clots such as deep vein thrombosis. If available, sequential compression devices can reduce risk (SCDs) (Kreutzer et al., 2016). Furthermore, patients should be encouraged to ambulate and move as soon as possible postoperatively. This also helps prevent deep vein thrombosis from occurring (Kreutzer et al., 2016).

The lithotomy position is used during gynecologic, rectal, and urologic surgeries. In this position, patients lie supine with their legs abducted from the midline and knees flexed. However, there are risks with this positioning, like nerve compression. At the end of a procedure, it is important to remove a patient from this position prior to extubation and return them to a supine position to increase lung compliance (Armstrong & Ross, 2022). Following neurosurgery, patients may be placed with their heads elevated to minimize swelling.

Patient positioning after surgery and anesthesia can also affect postoperative nausea and vomiting. Positional changes, especially as a patient is waking up from anesthesia or being transferred, can affect patients who are prone to motion sickness (Patterson et al., 2024). Patients who are sitting rather than supine, even during surgery, have a lower incidence of postoperative nausea and vomiting (Patterson et al., 2024).

Ultimately, positioning after surgery and anesthesia is a critical aspect of recovery. It aids in improving breathing, circulation, and discomfort while reducing the risk of complications including pressure ulcers and respiratory distress. By paying close attention to positioning, healthcare providers can significantly contribute to a smoother and more successful recovery for their patients.

References

Armstrong, Maggie. and Ross A. Moore. “Anatomy, Patient Positioning.” StatPearls, StatPearls Publishing, 31 October 2022.

Wang, Xinghe et al. “Semirecumbent Positioning During Anesthesia Recovery and Postoperative Hypoxemia: A Randomized Clinical Trial.” JAMA network open vol. 7,6 e2416797. 3 Jun. 2024, doi:10.1001/jamanetworkopen.2024.16797

Patterson, Heather et al. “Patient positioning and its impact on perioperative outcomes in children: A narrative review.” Paediatric anaesthesia vol. 34,6 (2024): 507-518. doi:10.1111/pan.14883

Kreutzer, Lindsey et al. “JAMA PATIENT PAGE. Preventing Venous Thromboembolism After Surgery.” JAMA vol. 315,19 (2016): 2136. doi:10.1001/jama.2016.1457

Elective surgery refers to a procedure that is scheduled in advance because it is not performed in an emergency situation. Unlike urgent or emergency surgeries, which are necessary to address acutely life-threatening conditions, elective surgeries are planned at times that are convenient for both the patient and the surgeon. This term encompasses a wide range of procedures, from cosmetic surgeries to important but non-emergency operations such as joint replacements or cataract removal.

Elective surgery is defined by its timing rather than its importance. While the word “elective” might imply that the procedure is optional, many elective surgeries are medically necessary. The main distinction is that these surgeries do not need to be performed immediately and can be scheduled at a later date.

Elective surgeries encompass a wide range of procedures, including cosmetic surgeries like rhinoplasty and breast augmentation, orthopedic surgeries such as hip or knee replacements, and weight-loss surgeries like gastric bypass or sleeve gastrectomy. Eye surgeries, including cataract removal or LASIK, are also common elective procedures, as are certain cardiac surgeries like pacemaker installation or heart valve repair, provided the condition is not immediately life-threatening. General surgeries, such as hernia repairs or gallbladder removal, also typically fall under the category of elective operations ^1–3.

Elective surgeries can generally be grouped into two categories based on their necessity and urgency. Medically necessary elective surgeries are procedures that, while not immediately required, are needed to improve a patient’s quality of life or to prevent a condition from worsening. For instance, a person with a painful knee joint due to arthritis might not need immediate surgery, but a knee replacement can significantly improve their ability to move and reduce pain. Similarly, surgeries like removing tumors that are non-cancerous but may cause future complications fall into this category. In contrast, optional or cosmetic elective surgeries are not essential for physical health but are chosen by the patient for personal reasons, often to enhance appearance or correct minor issues. Examples include facelifts, liposuction, or reconstructive procedures following trauma. While these surgeries are elective, they may have a significant psychological impact on a patient, improving self-esteem and confidence ^4,5.

Elective surgery offers several benefits, particularly for patients dealing with chronic conditions that affect their quality of life. By addressing issues like joint pain, vision impairment, or weight management, elective surgeries can provide significant physical and emotional relief. However, as with any surgical procedure, there are inherent risks. These risks depend on the type of surgery, the patient’s health, and the complexity of the procedure. Potential risks include infection, bleeding, complications from anesthesia, and postoperative recovery issues. Patients must weigh the potential benefits against the risks and discuss all concerns with their healthcare provider. Because elective surgeries are planned, patients have the advantage of time to consider their options, seek second opinions if necessary, and thoroughly research the procedure and potential outcomes ^6–9.

References

1.        Planned surgery (elective surgery) – Better Health Channel. Available at: https://www.betterhealth.vic.gov.au/planned-surgery-elective-surgery.

2.        Types of Surgery — Royal College of Surgeons. Available at: https://www.rcseng.ac.uk/patient-care/having-surgery/types-of-surgery/.

3.        Elective Surgery (for Parents) | Nemours KidsHealth. Available at: https://kidshealth.org/en/parents/elective.html.

4.        Elective Surgeries. Available at: https://www.adena.org/health-focus-blog/detail/adena-health-focus/2022/11/01/elective-surgeries.

5.        Different Types of Surgery | OakBend Medical Center. Available at: https://oakbendmedcenter.org/different-types-of-surgery/.

6.        The Pros and Cons of Elective Surgery: An In-Depth Analysis. Available at: https://www.kirbysurgicalcenter.com/the-pros-and-cons-of-elective-surgery-an-in-depth-analysis.html.

7.        Shaydakov, M. E. & Tuma, F. Operative Risk. (2023).

8.        Operative Risk – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK532240/. (Accessed: 6th October 2024)

9.        NHS England » New data demonstrates benefits to patients from a range of elective surgeries. Available at: https://www.england.nhs.uk/2016/08/benefit-to-patients/.

Peripheral nerve blocks are widely used in medical practice to provide pain relief during and after surgical procedures, as well as in the management of chronic pain. They involve the injection of anesthetic near a specific nerve or group of nerves to block sensation in a targeted area of the body ^1,2. While peripheral nerve blocks are generally considered safe and effective, they are not without potential downsides. Understanding these limitations is crucial for both healthcare providers and patients when considering this pain management option.

One of the downsides of peripheral nerve blocks is the risk of nerve damage. Although uncommon, improper needle placement or accidental puncture of the nerve can lead to temporary or permanent nerve injury. Symptoms of nerve damage may include numbness, tingling, weakness, or even paralysis in the affected area. In some cases, these symptoms may resolve over time, but in others, they can become permanent, leading to chronic pain or loss of function ³.

Infection is a potential complication of any procedure that involves breaking the skin, including peripheral nerve blocks. If proper sterile techniques are not followed, bacteria can be introduced into the injection site, leading to infection. Symptoms of infection may include redness, swelling, warmth, and pain at the injection site. In severe cases, an abscess may form, requiring further medical intervention. Additionally, there is a risk of hematoma formation, especially if the needle punctures a blood vessel. This can lead to localized bleeding and the development of painful swelling or a bruise ^3–5.

Patients may experience allergic reactions to the anesthetic agents used in peripheral nerve blocks. While allergic reactions are rare, they can range from mild (such as itching or rash) to severe (such as anaphylaxis, which is a life-threatening condition). It is important for healthcare providers to thoroughly review a patient’s medical history and any known allergies before administering a nerve block to minimize this risk ⁶.

While peripheral nerve blocks are generally effective, incomplete or failed blocks—when the anesthetic does not fully numb the intended area—come with several downsides including procedural delays, patient discomfort, and re-attempting the block or changing the anesthetic plan. Failed block can result from several factors, including incorrect needle placement, inadequate dosage of anesthetic, or anatomical variations in the patient. A failed block can lead to inadequate pain control during surgery or post-operatively, necessitating the use of additional pain management techniques, such as general anesthesia or systemic analgesics ³.

Systemic toxicity occurs when the anesthetic used in a nerve block is absorbed into the bloodstream at levels that can affect other parts of the body. This can happen if too much anesthetic is used or if the injection inadvertently enters a blood vessel. Symptoms of systemic toxicity can include dizziness, tinnitus (ringing in the ears), seizures, and cardiac arrest. Although rare, this is a serious complication that requires immediate medical attention ^3,6,7.

Peripheral nerve blocks are an important tool in pain management, offering significant benefits for patients undergoing surgery or dealing with chronic pain. However, like any medical procedure, peripheral nerve blocks come with risks and potential downsides. Understanding these risks is essential for making informed decisions about their use.

References

1.  Peripheral Nerve Blocks – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459210/.

2.  Nerve Block Pros and Cons: – Atlas Pain Specialists. Available at: https://atlaspainspecialists.com/nerve-block-pros-and-cons/.

3. Jeng, C. L., Torrillo, T. M. & Rosenblatt, M. A. Complications of peripheral nerve blocks. Br. J. Anaesth. (2010). doi:10.1093/bja/aeq273

4. Nerve Block: What It Is, Procedure, Side Effects & Types. Available at: https://my.clevelandclinic.org/health/treatments/12090-nerve-blocks.

5. Wiegel, M., Gottschaldt, U., Hennebach, R., Hirschberg, T. & Reske, A. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth. Analg. (2007). doi:10.1213/01.ane.0000261260.69083.f3

6. Local Anesthetic Systemic Toxicity and Allergy to Local Anesthetics | Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 3e | AccessAnesthesiology | McGraw Hill Medical. Available at: https://accessanesthesiology.mhmedical.com/content.aspx?bookid=3074&sectionid=255807496.

7. Wiederhold, B. D., Garmon, E. H., Peterson, E., Stevens, J. B. & O’Rourke, M. C. Nerve Block Anesthesia. StatPearls (2023).

Bariatric surgery is a very effective intervention for individuals with severe obesity, leading to significant and sustained weight loss, improvement in comorbid conditions, and enhanced quality of life ¹. Traditionally, bariatric surgery has been performed as an inpatient procedure, requiring patients to stay in the hospital for a few days post-operation. However, advancements in surgical techniques, anesthesia, and postoperative care have turned outpatient bariatric surgery into a viable option for some patients. Patients and their physicians must determine whether inpatient or outpatient bariatric surgery is the best option for them.

Inpatient bariatric surgery involves admitting the patient to the hospital for at least one night post-surgery. Often, this is done for more complex procedures or patients with higher risk profiles. Inpatient surgery allows for enhanced postoperative monitoring and immediate intervention if complications arise, which is particularly important for patients with significant comorbidities or those undergoing more complex procedures. In addition, patients receive comprehensive care, including pain management, nutritional support, and physical therapy, which can improve recovery outcomes. The hospital environment also provides a controlled setting with access to advanced medical equipment and specialists, enhancing overall patient safety ².

However, inpatient surgery is generally more expensive than outpatient surgery across procedures, including bariatric surgery, due to the extended hospital stay and additional resources required—for high-risk patients though, the increased cost is justified by the enhanced safety and monitoring ^3,4. Furthermore, a longer hospital stay can be inconvenient for patients and may increase the risk of hospital-acquired infections ⁵.

Outpatient bariatric surgery, also known as same-day surgery or ambulatory surgery, involves performing the surgical procedure with the expectation that the patient will be discharged within 24 hours—this is typically reserved for less complex procedures and patients with lower risk profiles.

The most significant advantage of outpatient bariatric surgery is removing the hospital stay ⁶. Patients can return to the comfort of their homes on the same day ⁴, which can improve patient psychological well-being and reduce the risk of hospital-acquired infections. In general, patients may find outpatient bariatric surgery thus more convenient than inpatient, as it reduces the disruption to their lives. In addition, outpatient bariatric surgery is generally more cost-effective compared to inpatient surgery due to the reduced need for prolonged hospital stays and associated resources ⁴.

Not all patients are suitable candidates for outpatient bariatric surgery, as the outpatient setting has reduced access to certain medical services ³. Ideal candidates are therefore typically younger, have a lower body mass index (BMI), and fewer comorbidities—comprehensive preoperative evaluation and risk stratification are essential. Furthermore, ensuring adequate postoperative care is crucial for outpatient procedures, since patients must have access to appropriate follow-up care, including emergency services if complications arise ⁴.

In conclusion, both outpatient and inpatient bariatric surgery have their unique advantages and considerations. In the end, the choice depends on patient-specific factors, the complexity of the procedure, and the availability of postoperative support.

References

1.          Bariatric surgery – Mayo Clinic. Available at: https://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258.

2.          Is Bariatric Surgery Inpatient or Outpatient?  – Acibadem Health Point International. Available at: https://www.acibademhealthpoint.com/the-is-bariatric-surgery-inpatient-or-outpatient/.

3.          Can the Gastric Sleeve Be Performed as Outpatient Surgery? Available at: https://www.masjax.com/gastric-sleeve-performed-on-an-outpatient-basis/.

4.          How does outpatient gastric sleeve surgery differ from inpatient procedures? Available at: https://gastricsleevelife.com/how-does-outpatient-gastric-sleeve-surgery-differ-from-inpatient-procedures/.

5.        Khan, H. A., Baig, F. K. & Mehboob, R. Nosocomial infections: Epidemiology, prevention, control and surveillance. Asian Pacific Journal of Tropical Biomedicine (2017). doi:10.1016/j.apjtb.2017.01.019

6.        Fortin, S. P., Kalsekar, I., Johnston, S. & Akincigil, A. Comparison of safety and utilization outcomes in inpatient versus outpatient laparoscopic sleeve gastrectomy: a retrospective, cohort study. Surg. Obes. Relat. Dis. (2020). doi:10.1016/j.soard.2020.07.012