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Variant Anatomy Literacy as a Patient-Safety Competency in Surgical Training: A Title-Informed Conceptual Review and Competency Framework
(Wiley Periodicals LLC, 2026-06-25) Sanchis-Gimeno, Juan A.; Zuld, Andreea-Bianca; Orellana-Donoso, Mathias; Valenzuela-Fuenzalida, Juan José; Granite, Guinevere
Surgical safety depends on recognition of patient-specific anatomy when encountered structures depart from population norms. Knowledge of anatomical variations is often treated as supplemental rather than as a safety-relevant necessity. This article aims to translate a title-informed map of literature on anatomical variation, surgical education, and patient safety into a practical competency framework for surgical training. A targeted, title-informed conceptual review was conducted in March 2026. PubMed was searched using anatomical-variation terms combined with surgery, education, patient safety, curriculum, assessment, simulation, reporting, and competency terms. PubMed Central, publisher pages, DOI landing pages, and cross-indexed scholarly sources were used for retrieval and verification. Titles and formal source descriptions were screened for signals linking anatomical variation with clinical risk, surgical error, curriculum, assessment, terminology, reporting, visualization, simulation, patient safety, or competency-based education. This method was designed for conceptual synthesis rather than prevalence estimation, effect-size analysis, or a complete evidence map. Six recurrent framings were identified: anatomical variation as a clinical hazard, curriculum and assessment gap, terminology and reporting problem, visualization and simulation challenge, team-communication and systems issue, and competency-based training target. These framings support defining variant anatomy literacy as the capability to anticipate, identify, interpret, adapt to, communicate, document and learn from clinically consequential anatomical variation before, during and after operative care. Surgical curricula should move beyond recall of rare variants and assess observable safety behavior under anatomical uncertainty. Practical implementation can integrate patient-specific imaging, donor contrast, simulation, operative observation, briefing and debriefing, operative-note audit, and morbidity-and-mortality learning.Surgical safety depends on recognition of patient-specific anatomy when encountered structures depart from population norms. Knowledge of anatomical variations is often treated as supplemental rather than as a safety-relevant necessity. This article aims to translate a title-informed map of literature on anatomical variation, surgical education, and patient safety into a practical competency framework for surgical training. A targeted, title-informed conceptual review was conducted in March 2026. PubMed was searched using anatomical-variation terms combined with surgery, education, patient safety, curriculum, assessment, simulation, reporting, and competency terms. PubMed Central, publisher pages, DOI landing pages, and cross-indexed scholarly sources were used for retrieval and verification. Titles and formal source descriptions were screened for signals linking anatomical variation with clinical risk, surgical error, curriculum, assessment, terminology, reporting, visualization, simulation, patient safety, or competency-based education. This method was designed for conceptual synthesis rather than prevalence estimation, effect-size analysis, or a complete evidence map. Six recurrent framings were identified: anatomical variation as a clinical hazard, curriculum and assessment gap, terminology and reporting problem, visualization and simulation challenge, team-communication and systems issue, and competency-based training target. These framings support defining variant anatomy literacy as the capability to anticipate, identify, interpret, adapt to, communicate, document and learn from clinically consequential anatomical variation before, during and after operative care. Surgical curricula should move beyond recall of rare variants and assess observable safety behavior under anatomical uncertainty. Practical implementation can integrate patient-specific imaging, donor contrast, simulation, operative observation, briefing and debriefing, operative-note audit, and morbidity-and-mortality learning.
Generative Artificial Intelligence Performance onUniversity-Level Human Anatomy Examinations:A Structured Narrative Review and ProposedMATRIX-Anatomy Framework
(Wiley Periodicals LLC, 2026-08-20) Sanchis-Gimeno, Juan A.; Valenzuela-Fuenzalida, Juan José; Bruna-Mejías, Alejandro; Orellana-Donoso, Mathias; Paton, Glen J.; Nalla, Shahed
Generative artificial intelligence (GenAI) can perform strongly on written anatomy examinations, but whether such scores represent anatomical competence remains uncertain because results vary with the model, assessment, protocol, modality, scoring, and comparator. We synthesized studies evaluating GenAI as the examinee in university-level human anatomy assessments and proposed MATRIX-Anatomy, a reporting and interpretive framework not yet externally validated. PubMed, Scopus, and Web of Science Core Collection were searched for records published from January 2022 to 11 July 2026. Eligible studies used university examinations, course item banks, or curriculum-aligned undergraduate benchmarks and reported quantitative performance. Three reviewers completed study selection, data extraction, and narrative synthesis by consensus. Of 115 records, 51 duplicates were removed, 64 were screened, and 15 studies were included. Leading systems scored 76% to 98% on text-based multiple-choice assessments. On a fixed 120-item set, accuracy increased from 45.8% with ChatGPT-3.5 to 86.7% with ChatGPT-5. Human comparisons were mixed. Visuospatial performance was weaker: ChatGPT-4o identified 22.26% of cadaveric structures after up to three attempts; ChatGPT-4.0 achieved 17.3% end-to-end accuracy on image-based anatomy; and ChatGPT-5.1 reached 74.4% on a surgical-anatomy subset. Repeated runs revealed volatility and consistently incorrect responses. The findings support supervised formative use with authoritative verification and retention of secure supervised, oral, constructed-response, visuospatial, and practical assessments. MATRIX-Anatomy specifies six domains (Model, Assessment, Testing protocol, Reference standard, Input, and eXternal validity) for reproducible reporting and defensible interpretation, but requires formal external validation.
Mediterranean diet and metabolic outcomes in nafld/masld: A systematic review and meta-analysis of randomized controlled trials
(Elsevier Ltd., 2026-10) Valenzuela-Fuenzalida, Juan José; Salazar-Arancibia, Tamara; Laborie-Reyes, Benjamin; Rodríguez-Ortiz, Francisco; Loaiza Giraldo, Jessica Paola; Salgado, Cristian; Nova-Baeza, Pablo; Orellana-Donoso, Mathias; Moya, Maria P.; Bruna Mejías, Alejandro; Cifuentes-Suazo, Gloria; Oyanedel-Amaro, Gustavo; Valenti, Vitor E.; Sanchis-Gimeno, Juan Alberto
Non-alcoholic fatty liver disease (NAFLD), recently redefined as metabolic dysfunction-associated steatotic liver disease (MASLD), is a leading cause of chronic liver disease worldwide. The Mediterranean diet (MD) is widely recommended for its metabolic benefits, but its specific impact on NAFLD/MASLD outcomes remains variable across trials. This systematic review and meta-analysis evaluated the effect of the Mediterranean diet on liver steatosis, liver enzymes, and metabolic markers in patients with NAFLD/MASLD. Larger, high-quality randomized trials with standardized dietary definitions and longer follow-up are required to clarify its therapeutic role in NAFLD/MASLD.
Unclosed transverse foramen of the atlas: A systematic review and meta-analysis of prevalence and translational anatomical relevance
(Elsevier, 2026-06-29) Sanchis-Gimeno, Juan A.; Orellana-Donoso, Mathias; Valenzuela-Fuenzalida, Juan José; Arlegi, Mikel; Paton, Glen J.; Nalla, Shahed; Gómez-Olivencia, Asier
Background: The atlas vertebra (C1) has a close anatomical relationship with the vertebral artery through the transverse foramen. Incomplete osseous closure of this canal, described as an unclosed transverse foramen (UTF), may modify the expected bony boundaries around the vertebral artery. Objective: This systematic review and meta-analysis estimated the prevalence of UTF in anatomically modern humans and summarized its anatomical and potential clinical implications. Methods: Searches were conducted in MEDLINE, CINAHL, Web of Science, Scopus and complementary sources following PRISMA 2020 and evidence-based anatomy recommendations. Eligible studies were original human anatomical, osteological, cadaveric, skeletal or imaging-based studies that reported C1-specific UTF with an extractable numerator and denominator. Methodological quality was assessed using the AQUA tool. Pooled prevalence was estimated using a random-effects model with logit-transformed proportions. Results: Six studies were included in the quantitative synthesis. The pooled prevalence of UTF was 8.8%, with negligible between-study heterogeneity. Methodological quality was predominantly favorable. Conclusions: UTF is an uncommon but recurrent anatomical variant of the atlas. Current evidence does not establish isolated UTF as an independent cause of symptoms. The variant should nevertheless be recognized in anatomical description, radiological reporting and preoperative planning for upper cervical procedures.
Effects of Zinc Supplementation on Glycemic Control, Insulin Resistance, Inflammation and Oxidative Stress in Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
(John Wiley & Sons Ltd., 2026-06-05) Loaiza-Giraldo, Jessica Paola; Amigo-Fierro, Florencia; Cancino-Castro, Camila Ignacia; Donoso-Emig, Matias; Satea, Murtaja; Farías-Quinteros, Ignacia; Bruna-Mejias, Alejandro; Nova-Baeza, Pablo; Orellana-Donoso, Mathias; Gutiérrez-Espinoza, Héctor; Cifuentes-Suazo, Gloria; Sanchis-Gimeno, Juan; Piagkou, Maria; Valenti, Vitor E.; Leon-Rojas, Jose E.; Valenzuela-Fuenzalida, Juan José
Objectives: Diabetes mellitus (DM) is a chronic metabolic disorder characterized by insulin resistance, impaired insulin secretion, and increased cardiometabolic and inflammatory burden. Zinc plays a key biological role in insulin synthesis, storage, signalling and antioxidant defence; however, the clinical relevance and consistency of zinc supplementation effects in diabetes remain uncertain. Methods: A systematic search of PubMed/MEDLINE, Web of Science, Scopus, CINAHL and Google Scholar was conducted to identify randomized controlled trials (RCTs) assessing zinc supplementation in individuals with diabetes, gestational diabetes or prediabetes. Results: Eighteen RCTs involving 1023 participants met the eligibility criteria. Zinc supplementation significantly increased plasma zinc concentrations (MD = 7.80; 95% CI 4.33 to 11.26) and improved insulin resistance, as reflected by reductions in serum insulin (MD = -2.50; 95% CI -4.69 to -0.31) and HOMA-IR (MD = -1.10; 95% CI -2.05 to -0.15). Total cholesterol decreased modestly but significantly (MD = -5.70; 95% CI -7.50 to -3.89), representing a relatively small absolute reduction, while LDL cholesterol showed a modest increase (MD = 3.46; 95% CI 1.48 to 5.43), although the clinical relevance of this finding remains uncertain. Inflammatory and oxidative stress markers improved, including reductions in C-reactive protein (SMD = -0.91; 95% CI -1.43 to -0.38) and malondialdehyde (SMD = -0.76; 95% CI -1.34 to -0.18), alongside an increase in total antioxidant capacity (SMD = 1.79; 95% CI 0.68 to 2.91). Conclusions: Zinc supplementation was associated with improvements in insulin resistance, inflammatory status and oxidative stress markers in individuals with diabetes.
Activity and Outcomes of a Multidisciplinary Sepsis Unit: Fifty Thousand Consultations over Thirteen Years
(MDPI, 2026-07-30) Borges-Sa, Marcio
Resumen: Background. Sepsis is a leading, time-dependent cause of in-hospital death, and guidelines now prioritize organized care such as code-sepsis protocols. Yet little is known about the long-term activity, organization and outcomes of permanent, hospital-scale programs. We characterized the activity of a hospital-wide multidisciplinary sepsis unit (MSU) over thirteen years and evaluated mortality trends. Methods. Retrospective cohort study using the registry of a hospital-wide MSU (2011-2023). The analysis unit was the sepsis event. Activity, referral pathways, interventions, follow-up and mortality were analyzed; temporal trends used multivariable logistic regression and standardized mortality ratios (SMR). Results. The unit attended 10,874 patients across 15,723 events and 50,925 consultations (median age 67; 59.3% men), referred mainly through the sepsis code (45.0%) and, increasingly, proactive early-warning detection (15.2%). An antibiotic change was recommended in 57.2% of events, and 89.8% of all suggested changes were implemented. Follow-up was sustained (median 3 visits; 61.8%). In-hospital mortality was 7.6%, and 11.8% in protocol-confirmed sepsis. Crude mortality did not fall, but severity rose (organ dysfunctions 1.67 to 2.72; septic shock 8 to 13%; both p < 0.001) with stable age; after adjustment the calendar-year effect disappeared (adjusted OR 1.00/year p = 0.70) and the SMR stayed near 1.0, including pandemic years. Age, ICU admission (OR 2.65) and organ-dysfunction count (OR 1.37) independently predicted death. Conclusions. Over thirteen years, this hospital-wide MSU delivered large-scale, multi-channel, longitudinal care to an increasingly severe population while maintaining stable risk-adjusted mortality, supporting the long-term feasibility of a model integrating early detection, multidisciplinary decision-making, antimicrobial stewardship and follow-up.
The PRECISE framework: a structured approach to antibiogram interpretation for antimicrobial optimization at the bedside
(Sociedad Española de Quimioterapia, 2026-08-31) Pérez-Oliva, Claudio
Resumen: Antimicrobial resistance claimed an estimated 4.95 million lives in 2019. When clinicians prescribe empiric therapy that follows guidelines, mortality drops by roughly a third; when they de-escalate on the basis of culture results, it drops by more than half. Yet the document that should drive both decisions, the antibiogram, is often read superficially or misinterpreted, particularly by physicians without infectious-disease training. Existing stewardship frameworks address prescribing principles, timing, or ecological impact, but none walks the clinician step by step through an individual susceptibility report and out the other side with a treatment plan. PRECISE is a seven-step mnemonic designed for that purpose. Each letter corresponds to a clinical action: Pathogen assessment, Resistance phenotype interpretation, Evaluate MIC, Curtail spectrum, Individualize PK/PD, Switch route, and Endpoint optimization. Three clinical vignettes (including one in which the steps deliberately collide) illustrate how the framework operates in practice.
Prospective economic evaluation of a predictive artificial intelligence model for sepsis: Effects on hospital costs and return on investment
(PLOS, 2026-08-31) Giglio, Andres
Resumen: Early sepsis detection is essential for improving outcomes and reducing costs, but traditional rule-based systems have limited accuracy and real-world evidence for machine-learning alternatives remains scarce. In this context, BIAlert-Sepsis predicts sepsis risk within 24 hours using historical hospital data, and evaluating its implementation in a tertiary hospital setting provides an opportunity to quantify its clinical benefits and economic value. We conducted a retrospective quasi-experimental before–after study including all septic patients admitted from January 2011 to June 2024. The baseline period (Jan 2011 – Mar 2019) was compared with the AI implementation period (Apr 2019 – June 2024), excluding the COVID-19 interval. Outcomes were assessed using adjusted generalized linear models and interrupted time series regression. A hospital-perspective economic evaluation incorporated implementation and maintenance costs, and a 5-year model estimated net benefit and return on investment (ROI), supported by deterministic and probabilistic sensitivity analyses. A total of 8,039 patients were included (6,168 baseline period; 1,871 AI period). Demographic and clinical characteristics were comparable across periods. During the AI period, ICU admissions decreased from 34.4% to 30.4% (adjusted p = 0.001), accompanied by significant reductions of 0.35 ICU days and 0.59 ward days per patient. Mean admission costs declined from 26,517€ to 24,630€ (adjusted p = 0.005). After covariate adjustment, AI implementation was associated with a 26.1–31.1% reduction in mean admission costs across GLM models. Interrupted time series analysis identified a modest immediate cost level change after AI implementation and a larger sustained decline during the post-COVID period. The 5-year economic model projected a cumulative discounted net benefit of 3.55M€ and a 528% ROI. BIAlert-Sepsis was associated with favourable clinical outcomes and lower costs, with economic modelling suggesting early breakeven and positive financial returns
A Respiratory Therapist-Driven High-Flow Nasal Cannula Liberation Protocol at High Altitude.
(SAGE Publications, 2026-08-26) Vásquez Hoyos, Pablo
Background: High-flow nasal cannula (HFNC) liberation strategies in pediatric intensive care often transition patients directly from HFNC to room air. At high altitude, oxygen requirements may persist after flow-dependent respiratory support is no longer needed. We evaluated the association between a protocolized, respiratory therapist-driven HFNC liberation strategy and time to successful liberation from high-flow support in children with acute respiratory failure. Methods: We conducted a retrospective cohort study using prospectively collected LARed Network registry data from a tertiary PICU in Bogotá, Colombia (2,600 m altitude). In September 2022, the unit implemented an HFNC liberation strategy designed to separate persistent oxygen requirement from ongoing need for high-flow support. The primary analysis included the first HFNC episode per PICU admission from March 2018 to March 2025. The primary outcome was time to successful HFNC liberation. Kaplan-Meier curves and multivariable Cox regression were used; gamma log-link models were used for sensitivity analyses, including a prespecified bronchiolitis subgroup. Results: We included 1,086 PICU admissions, 627 before and 459 after implementation. Median HFNC duration decreased from 59.8 h (interquartile ranges [IQR] 34.7-91.4) to 53.1 h (IQR 32.3-80.5, P = .01). Kaplan-Meier analysis showed earlier HFNC liberation after implementation (log-rank P < .01). Implementation was associated with earlier liberation in adjusted Cox regression (hazard ratio 1.17, 95% CI 1.03-1.34, P = .02). PICU stay decreased from 4.7 days (IQR 3.2-6.9) to 4.0 days (IQR 2.9-5.8, P < .01). In bronchiolitis, implementation was associated with an 18.2% relative reduction in HFNC duration (95% CI 7.7-27.5%, P < .01). Conclusions: In a high-altitude PICU, a respiratory therapist-driven HFNC liberation strategy was associated with earlier liberation from high-flow support. A strategy that preserves oxygen delivery while testing tolerance of minimal flow may be useful in high-altitude settings
Adenovirus Versus Respiratory Syncytial Virus in Children With Severe Viral Acute Respiratory Failure: A Multicenter Latin American Cohort.
(Wolters Kluwer Health, 2026-08-26) Barajas-Romero, Juan Sebastián
Background: Respiratory syncytial virus (RSV) commonly causes severe lower respiratory tract disease. Adenovirus is detected less often, but severe pneumonia may occur. The pediatric intensive care unit (PICU) course associated with adenovirus detection compared with RSV-only detection is not well defined. Methods: We studied clinician-tested, virus-positive PICU admissions of children aged 1 month to 18 years from 37 PICUs in 7 Latin American countries (2017-2025). Children with RSV and/or adenovirus detection who used respiratory support were grouped as RSV-only, adenovirus-only or RSV-adenovirus codetection. The primary outcome was PICU death or worse functional status at discharge. Adjusted associations were estimated with logistic regression; Firth penalization was used for mortality. Results: Among 3196 PICU admissions, 2859 had RSV-only, 257 adenovirus-only and 80 codetection. PICU mortality was 12/257 (4.7%) in adenovirus-only, 13/2859 (0.5%) in RSV-only and 2/80 (2.5%) in codetection. Compared with RSV-only detection, adenovirus-only detection was associated with mortality [adjusted odds ratio (OR): 10.56; 95% confidence interval (CI): 4.57-24.43] and with PICU death or worse functional status at discharge [21/222 (9.5%) vs 45/2308 (1.9%); adjusted OR: 6.57; 95% CI: 3.59-12.03]. Among nonsurvivors, the median PICU day of death was 3 (IQR: 2-6) with adenovirus-only detection and 8 (IQR: 3-9) with RSV-only detection. Conclusions: In this multicenter Latin American PICU cohort, adenovirus-only detection was associated with a higher-risk acute course than RSV-only detection, including higher mortality and worse functional status at PICU discharge.
Automated segmentation of postsurgical resection cavities on magnetic resonance imaging in focal epilepsy: A Multicentre Epilepsy Lesion Detection study
(John Wiley & Sons, 2026-08-19) Seo, Jieun; Ripart, Mathilde; Kaas, Helene; Kronlage, Cornelius; Sinclair, Ben; Vivash, Lucy; Courtney, Merran R.; O'Brien, Terence J.; Gopinath, Siby; Parasuram, Harilal; Kandemirli, Sedat; Alarab, Natally; Lai, Lillian; Likeman, Marcus; Zhang, Kai; Mo, Jiajie; Ciobotaru, Georgian; Galea, James; Sequeiros-Peggs, Philip; Hamandi, Khalid; Xie, Hua; Illapani, Venkata Sita Priyanka.; Gaillard, William D.; Cohen, Nathan T.; Weil, Alexander G.; Henrichon-Goulet, Florence; Lahlou, Kenza S.; Hadjinicolaou, Aristides; Ibáñez, Agustín; Rojas-Costa, Gonzalo M.; Urbach, Horst; Bücheler, Lara; Heers, Marcel; Valls Carbó, Adrián; Toledano, Rafael; Nobile, Giulia; Parodi, Costanza; Tortora, Domenico; Consales, Alessandro; Riva, Antonella; Severino, Mariasavina; Tisdall, Martin; D'Arco, Felice; Mankad, Kshitij; Chari, Aswin; Eriksson, Maria H.; Piper, Rory J.; Cross, J. Helen; Baldeweg, Torsten; González-Ortiz, Sofia; Pariente, Jose; Bargalló, Nuria; Liu, Yawu; Kälviäinen, Reetta; Barba, Carmen; Lenge, Matteo; Guerrini, Renzo; Iwasaki, Masaki; Sone, Daichi; Maki, Hiroyuki; Imokawa, Tomoki; Sato, Noriko; Jung, Julien; Sepulveda, Francisco; Mansilla, Daniel; Goycoolea, Andres; Lopez, Ingeborg; Napolitano, Antonio; De Benedictis, Alessandro; De Palma, Luca; Rossi-Espagnet, Maria Camilla; Kondylidis, Nikolaos; Gkiatis, Kostakis; Garganis, Kyriakos; Pepper, Joshua; Seri, Stefano; Duncan, John S.; Yasuda, Clarissa L.; Scárdua-Silva, Lucas; Alvim, Marina K. M.; Cendes, Fernando; Gennari, Antonio G.; O'Gorman Tuura, Ruth; Ramantani, Georgia; Josyula, Mariam; Stein, Joel; Sinha, Nishant; Davis, Kate; Hogan, R. Edward.; Maccotta, Luigi; Adler, Sophie; Wagstyl, Konrad
Objective Quantitative assessment of extent of tissue resection following epilepsy surgery requires accurate delineation of the resection cavity on postoperative magnetic resonance imaging (MRI). Current methods for resection cavity masking are time-consuming and labor-intensive, and existing automated approaches exhibit variable segmentation accuracy, particularly on extratemporal resections. We developed MELD-PostOp, a deep learning tool trained and evaluated on a large, heterogeneous cohort to automatically segment resection cavities. Methods The study included 1.5- and 3T postoperative three-dimensional T1-weighted MRI images from the Multicentre Epilepsy Lesion Detection (MELD) project (nsubjects = 969, 27 centers) and from the EPISURG dataset (n = 133). The cohort included children and adults, alongside a range of resection locations, pathologies, and MRI characteristics. Resection cavities were individually segmented in 285 subjects and used to train an nnU-Net prototype model. The prototype model was used to generate an additional 680 resection masks, which were subsequently quality-controlled, edited, and combined with the original 285 to train the final MELD-PostOp model (n = 965). A Stratified Test Cohort (n = 50) and Independent Test Cohort (n = 87) were withheld for model evaluation. Performance was evaluated using Dice similarity coefficient (DSC), 95th percentile Hausdorff distance (HD95), number of predicted clusters, and inference runtime, and compared against established tools (Epic-CHOP, ResectVol, and RESSEG). Results MELD-PostOp achieved a median DSC of .85 and HD95 of 3.61 on the combined test cohort, outperforming Epic-CHOP (DSC .69, HD95 9.67), ResectVol (DSC .66, HD95 15.05), and RESSEG (DSC .43, HD95 32.67), with significant improvements seen in both temporal and especially extratemporal resections. The model detected 98.5% (135/137) of resection cavities. MELD-PostOp runtime was 17 s per MRI, compared to 612 s (ResectVol), 3205 s (Epic-CHOP), and 4 s (RESSEG). MELD-PostOp performance remained high across clinical and imaging subgroups (median DSC > .8). Significance MELD-PostOp is an open-source research tool that provides an accurate, efficient, and generalizable solution for postoperative resection cavity segmentation using only postoperative MRI scans.
Mapping intensive care across Ibero-America: The FEPIMCTI multinational survey of bed capacity, workforce, and pandemic response
(Elsevier, 2022-07-26) Matos, Alfredo
Background: Intensive care resources are unequally distributed across Ibero-America, and reliable comparable data are scarce, hindering cross-national comparison and health-system planning. Methods: We conducted a cross-sectional survey of the 25 national critical care societies affiliated with FEPIMCTI. Presidents or designated representatives reported country-level data on ICU beds, intensivist and nursing workforce, organizational models, training pathways, and surge capacity before and during the COVID-19 pandemic. Resource density was summarized as the country-level median with IQR and as the population-weighted regional rate. Results: Twenty-one countries, including Spain and Portugal, participated, representing 693.6 million inhabitants. A total of 78,723 ICU beds were reported (country-level median 6.1 per 100,000, IQR 3.3–12.4; population-weighted rate 11.3), with public ICUs accounting for 51.6%. A total of 23,803 intensivists were identified (median 2.6 per 100,000, IQR 1.0–5.0), with five countries below 1 per 100,000. Nurse-to-patient ratios ranged from 1:1 to 1:7, and universal 24/7 intensivist coverage was reported in only a subset of countries. During the pandemic, ICU bed capacity rose 69%; among the 20 countries with data for both periods, physician involvement rose 32%, largely through redeployment of non-intensivists rather than growth of the certified workforce. Conclusions: Critical care capacity, workforce, and organization vary widely across Ibero-America, with many countries below high-income benchmarks and pandemic surges met largely through temporary redeployment. These findings provide the first coordinated regional benchmark to guide workforce development, standardized training, and organizational strengthening.
Service-Specific Heterogeneity in Sepsis Variable Significance and Machine Learning Model Performance: A Stratified Analysis of the BIAlert Cohort
(MDPI, 2026-06-24) Borges-Sa, Marcio
Background/Objectives: Sepsis detection relies on clinical variables and scoring systems assumed to perform uniformly across hospital settings. However, sepsis phenotype distributions shift between clinical environments, suggesting that variable importance may be setting dependent. This study aimed to quantify service-specific variability in the discriminatory capacity of clinical variables for sepsis detection and to evaluate whether this heterogeneity translates into differential performance of machine learning models compared to traditional clinical scoring systems. Methods: This stratified sub-analysis of the BIAlert Sepsis cohort (203,755 patients; 11,864 sepsis episodes, 2014–2018) evaluated 61 structured quantitative variables across nine hospital services (≥90 sepsis episodes each). Within each service, the Mann–Whitney–Wilcoxon test (p < 0.01, Holm-corrected) assessed differences between septic and non-septic episodes. Five machine learning models (Random Forest/BIAlert, XGBoost, CatBoost, SVM, Neural Network) and three clinical rules (NEWS, SIRS, qSOFA) were evaluated globally and stratified across four clinical environments. Results: The proportion of significant variables ranged from 95.1% in the Emergency Department (58/61) to 37.7% in the Intensive Care Unit (23/61). Lactate was the only universally significant variable (9/9 services). Clinical scoring systems collapsed in Critical Care (qSOFA and NEWS AUC 0.459). BIAlert maintained the highest AUC across all environments (0.975–0.857). The Friedman test confirmed significant differences (χ2 = 28.00, p < 0.001), with BIAlert achieving a mean rank of 1.0. Conclusions: The discriminatory capacity of clinical variables for sepsis detection is not uniform across hospital services. ML models, particularly BIAlert, maintained robust performance where fixed-rule scoring systems failed.
From development to clinical practice: deployment of an interoperable and secure ML-based CDSS to aid in the early detection of sepsis
(Elsevier, 2026-06-17) Serrano García, Ana
Recent research has increasingly focused on machine learning (ML) models for early disease prediction, yet practical frameworks for integrating these models into clinical workflows remain limited. BIAlert is a microservices-based framework designed to operate as a real-time early-warning system for ML-driven disease prediction in hospitalised patients. It can be deployed remotely on physical or virtual servers and is composed of coupled microservices that communicate through Apache Kafka queues, using HL7 FHIR resources as the message format. The system comprises four core components: (1) the Connector, which ingests raw hospital data and converts it into standardised healthcare formats; (2) the Writer, which stores FHIR-formatted data in an internal database and triggers the prediction pipeline; (3) the Predictor, which hosts ML models and generates patient-specific alerts; and (4) the Model Evaluator, which supports prospective monitoring of model performance. Alerts are displayed through the BIAlert user interface and can also be integrated directly into the electronic health record (EHR). BIAlert is currently deployed and operating in real-time clinical settings in two hospitals, demonstrating its feasibility as a scalable and interoperable solution for ML-based clinical decision support.
The ICU pharmacist’s contribution to antimicrobial optimization through routine pharmacist interventions
(Revista Española de Quimioterapia, 2026-07-08) Sánchez-Ocaña, Natalia
Background: Antimicrobials are among the medication groups most frequently involved in medication errors and adverse drug events in the Intensive Care Unit (ICU). Despite growing evidence supporting the role of Critical Care Pharmacists (CCPs) in antimicrobial stewardship, their integration into ICU teams remains inconsistent across European healthcare systems. Methods: A prospective observational study was conducted over five months in an 18-bed medical-surgical ICU at a tertiary-level hospital in Spain. All admitted patients were included. A specialist pharmacist reviewed daily antimicrobial prescriptions through the electronic prescribing system. Pharmaceutical interventions (PIs) were classified as proactive or reactive and categorised by intervention type according to a predefined taxonomy. A descriptive analysis was performed. Results: A total of 331 PIs were recorded, of which 150 (45.31%) corresponded to antimicrobial therapy, representing the most frequently involved medication group. This figure corresponds to a mean of 1.50 antimicrobial-related PIs per working day. Of these, 115 (76.67%) were proactive. The most frequent intervention type was dose adjustment for overdosing or excessive duration (47.33%), followed by dose adjustment for underdosing or insufficient duration (18.00%), therapeutic drug monitoring recommendations (10.67%), and drug information to clinical staff (6.66%). Conclusions: CCPs identify a substantial number of antimicrobial-related drug problems in the ICU through routine prospective review. The coexistence of overdosing and underdosing interventions reflects the pharmacokinetic complexity of this population. These findings support the formal integration of CCPs into ICU antimicrobial stewardship activities.
Activity and Outcomes of a Multidisciplinary Sepsis Unit: Fifty Thousand Consultations over Thirteen Years
(MDPI, 2024-07-26) Borges-Sa, Marcio
Background. Sepsis is a leading, time-dependent cause of in-hospital death, and guidelines now prioritize organized care such as code-sepsis protocols. Yet little is known about the long-term activity, organization and outcomes of permanent, hospital-scale programs. We characterized the activity of a hospital-wide multidisciplinary sepsis unit (MSU) over thirteen years and evaluated mortality trends. Methods. Retrospective cohort study using the registry of a hospital-wide MSU (2011–2023). The analysis unit was the sepsis event. Activity, referral pathways, interventions, follow-up and mortality were analyzed; temporal trends used multivariable logistic regression and standardized mortality ratios (SMR). Results. The unit attended 10,874 patients across 15,723 events and 50,925 consultations (median age 67; 59.3% men), referred mainly through the sepsis code (45.0%) and, increasingly, proactive early-warning detection (15.2%). An antibiotic change was recommended in 57.2% of events, and 89.8% of all suggested changes were implemented. Follow-up was sustained (median 3 visits; 61.8%). In-hospital mortality was 7.6%, and 11.8% in protocol-confirmed sepsis. Crude mortality did not fall, but severity rose (organ dysfunctions 1.67 to 2.72; septic shock 8 to 13%; both p < 0.001) with stable age; after adjustment the calendar-year effect disappeared (adjusted OR 1.00/year, p = 0.70) and the SMR stayed near 1.0, including pandemic years. Age, ICU admission (OR 2.65) and organ-dysfunction count (OR 1.37) independently predicted death. Conclusions. Over thirteen years, this hospital-wide MSU delivered large-scale, multi-channel, longitudinal care to an increasingly severe population while maintaining stable risk-adjusted mortality, supporting the long-term feasibility of a model integrating early detection, multidisciplinary decision-making, antimicrobial stewardship and follow-up.
International multidisciplinary consensus statement on sepsis code guidelines: A Delphi approach
(John Wiley & Sons Ltd, 2024-08-26) Borges-Sa, Marcio
Background. Sepsis remains a major global health challenge. International guidelines exist, but their implementation is inconsistent, and supporting evidence largely comes from high-income settings. The objective of this study was to generate international, multidisciplinary expert consensus on controversial aspects of sepsis management within the framework of sepsis code programs. Methods. A multinational modified Delphi study was conducted with 164 experts from 22 countries, 12 specialties, and 105 scientific societies. Seven domains were evaluated: early diagnosis, biomarkers, diagnostic microbiology, hemodynamic monitoring, source control, antimicrobial therapy, and hemodynamic management. Consensus was defined as ≥70% agreement across three iterative rounds using Likert scales (Rounds 1–2) and binary format (Round 3). Results. Consensus was achieved for 40 statements. Strong endorsement (82%–95%) was reached for structured hospital sepsis programs, NEWS-2 as the preferred early recognition tool, biomarker use (notably procalcitonin) to complement clinical assessment, urgent source control within 6 h independent of hemodynamic status, rapid molecular diagnostics integrated with antimicrobial stewardship, and norepinephrine as first-line vasopressor therapy. Experts also supported pharmacokinetic- and pharmacodynamic-guided antibiotic dosing, prolonged infusion of time-dependent agents, and dynamic rather than fixed fluid strategies. No consensus was reached on routine reliance on Sepsis-2, Sepsis-3, or qSOFA; high mean arterial pressure targets; or universal combination antimicrobial therapy. Conclusions. These results provide multidisciplinary guidance for sepsis management, with emphasis on rapid recognition, targeted antimicrobial therapy, timely source control, and hemodynamic management guided by patient physiology. The recommendations are applicable to high- and middle-income healthcare systems.
Preoperative dynamic anterior tibial translation is not predictive of graft rupture after anterior cruciate ligament reconstruction
(John Wiley & Sons Inc., 2026) Pineda, Tomás
Purpose: This study aimed to determine whether higher preoperative dynamic anterior tibial translation (DATT) using laximetry is a risk factor for graft rupture after anterior cruciate ligament reconstruction (ACLR). Methods: This retrospective study included all patients who underwent primary ACLR with hamstring autograft between January 2014 and December 2017. Demographic data, absolute DATT on the injured side and ΔDATT (side‐to‐side difference), posterior tibial slope (PTS), static anterior tibial translation (SATT), concomitant lateral extra‐articular tenodesis (LET) and meniscal tears were collected. Subgroup analysis was performed using a ΔDATT threshold of 6 mm. Univariate and multivariable logistic regression analyses were conducted to identify independent risk factors for ACL graft rupture. Results: Among the 680 patients included with a minimum follow‐up of 6 years, 41 (6%) experienced graft rupture at a mean of 45 ± 30 months postoperatively. The median DATT on the injured side was 9 mm [inter- quartile range, IQR, 5], and the median ΔDATT was 6 mm [IQR, 4]. Graft rupture occurred in 5.8% for patients with ΔDATT < 6 mm and in 6.3% for patients with ΔDATT ≥ 6 mm (p = 0.787). Patients with ΔDATT ≥ 6 mm demonstrated a higher prevalence of medial meniscal tears (31% vs. 24%, p = 0.026). Independent risk factors for graft rupture included PTS ≥ 12° (odds ratio [OR] 3.1; 95% confidence interval [CI], 1.6–6.3; p < 0.001) and SATT ≥ 5 mm (OR 2.6; 95% CI, 1.2–5.5; p = 0.027), whereas neither ΔDATT nor absolute DATT was significantly associated with graft rupture. Conclusion: Preoperative DATT is not predictive of graft rupture following ACLR using hamstring autograft. PTS and SATT remain stronger predictors and should be prioritised for preoperative risk stratification.
Anterior tibial translation versus rotational instability in ACL reconstruction: Defining the problem before choosing the procedure
(John Wiley & Sons Inc., 2026) Pineda, Tomás
The expanding use of lateral extra‐articular procedures (LEAPs) and tibial deflexion osteotomy (TDO)—also referred to as slope‐reducing anterior closing wedge high tibial osteotomy—in anterior cruciate ligament (ACL) reconstruction reflects meaningful progress in our understanding of mechanisms of graft failure. However, as their use expands, an important distinction must be maintained: they do not address the same problem.
Confirmation bias in orthopaedic surgery: the challenge of the information overload era
(Elsevier, 2026) Pineda, Tomás
Modern orthopaedic practice takes place in a context of information abundance. Clinical trials, national registries, systematic reviews, and meta-analyses are published constantly, producing more evidence than any clinician can follow. Over the past decade, the number of publications in high-impact orthopaedic journals has grown steadily, with post-pandemic years showing a particularly steep increase. One might expect that more evidence leads to better and more objective decisions. However, having access to information does not always guarantee that new studies are interpreted without bias

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