Sepsis-associated encephalopathy (SAE) remains a challenge for intensivists that is exacerbated by lack of an effective diagnostic tool and an unambiguous definition to properly identify SAE patients. Risk factors for SAE development include age, genetic factors as well as pre-existing neuropsychiatric conditions. Sepsis due to certain infection sites/origins might be more prone to encephalopathy development than other cases. Currently, ICU management of SAE is mainly based on non-pharmacological support. Pre-clinical studies have described the role of the alarmin high mobility group box 1 (HMGB1) in the complex pathogenesis of SAE. Although there are limited data available about the role of HMGB1 in neuroinflammation following sepsis, it has been implicated in other neurologic disorders, where its translocation from the nucleus to the extracellular space has been found to trigger neuroinflammatory reactions and disrupt the blood–brain barrier. Negating the inflammatory cascade, by targeting HMGB1, may be a strategy to complement non-pharmacologic interventions directed against encephalopathy. This review describes inflammatory cascades implicating HMGB1 and strategies for its use to mitigate sepsis-induced encephalopathy.

Aseptic surgical trauma provokes the release of HMGB1, which engages the innate immune response after binding to pattern-recognition receptors on circulating bone marrow-derived monocytes (BM-DM). The initial systemic inflammation, together with HMGB1, disrupts the blood–brain barrier allowing penetration of CCR2-expressing BM-DMs into the hippocampus, attracted by the chemokine MCP-1 that is upregulated by HMGB1. Within the brain parenchyma quiescent microglia are activated and, together with the translocated BM-DMs, release proinflammatory cytokines that disrupt synaptic plasticity and hence memory formation and retention, resulting in postoperative cognitive decline (PCD). Neutralizing antibodies to HMGB1 prevents the inflammatory response to trauma and PCD.

This article explores challenges for bridging the gap between scientists and healthcare professionals in artifical intelligence (AI) integration. It highlights barriers, the role of interdisciplinary research centers, and the importance of diversity, equity, and inclusion. Collaboration, education, and ethical AI development are essential for optimizing AI’s impact in perioperative medicine.

Older adults undergoing surgery often face numerous challenges to healthcare decisions due to frailty, comorbidities and varying personal priorities. Shared decision-making (SDM) is a patient-centred approach that enhances peri-operative care by aligning medical decisions with individual values and preferences. When considering surgery for an older adult, SDM can ensure that the surgical treatment plan focuses on what older adults find important, such as quality of life (QOL), functional independence, long-term well being and survival. This narrative review explores the role of SDM in peri-operative care of older adults and strategies for increasing SDM in this context. SDM fosters collaboration between patients, families and healthcare teams; as a result, it can lead to improved patient satisfaction, reduced decisional conflict and greater trust between patients and their medical teams. However, integrating SDM into routine practice remains complex due to cognitive impairment, communication barriers, time constraints and gaps in evidence. Effective SDM strategies include enhancing interdisciplinary collaboration, improving clinician and staff training, developing decision aids tailored to older adults considering surgery and leveraging technology to support patient engagement. Future efforts should focus on expanding SDM research, refining implementation frameworks and advocating for policy changes that facilitate patient-centred surgical decision-making in older adults. As the global population ages, prioritising SDM in peri-operative care will be critical to optimising patient outcomes, ensuring ethical, informed decision-making and aligning care plans with the patient's goals and values.