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BackgroundPerformance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.ObjectiveOur aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.MethodsWe systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.ResultsWe screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.ConclusionApart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

Background Until a few years ago, surgical professionals mainly practiced using a combination of cadaver or (live) animal training, 1,2 complemented by clinical observations and hands-on training with real patients. 3,4 The idea to introduce simulations for medical teaching is not new. Simple forms of physical models have been used for teaching the human anatomy long before computerassisted exercises were possible. 5 Yet, technical progress nowadays opens up further opportunities, particularly through the introduction of high-fidelity virtual reality (VR) patient simulators. 6 The benefits of technology-enhanced simulations in surgical education include simulations that yield opportunities to repeat certain procedure steps multiple times to target specific skill sets. 7 Patient safety is safeguarded since surgeons are allowed to prepare themselves specifically for certain cases, and novices are trained in safe 822869S RIXXX10.

Background Non-technical skills (NTS) are essential for safe surgical practice as they impact workflow and patient outcomes. Observational tools to measure operating room (OR) teams’ NTS have been introduced. However, there are none that account for the specific teamwork challenges introduced by robotic-assisted surgery (RAS). We set out to develop and content-validate a tool to assess multidisciplinary NTS in RAS. Methodology Stepwise, multi-method procedure. Observations in different surgical departments and a scoping literature review were first used to compile a set of RAS-specific teamwork behaviours. This list was refined and expert validated using a Delphi consensus approach consisting of qualitative interviews and a quantitative survey. Then, RAS-specific behaviours were merged with a well-established assessment tool on OR teamwork (NOTECHS II). Finally, the new tool—RAS-NOTECHS—was applied in standardized observations of real-world procedures to test its reliability (inter-rater agreement via intra-class correlations). Results Our scoping review revealed 5242 articles, of which 21 were included based on pre-established inclusion criteria. We elicited 16 RAS-specific behaviours from the literature base. These were synthesized with further 18 behavioural markers (obtained from 12 OR-observations) into a list of 26 behavioural markers. This list was reviewed by seven RAS experts and condensed to 15 expert-validated RAS-specific behavioural markers which were then merged into NOTECHS II. For five observations of urologic RAS procedures (duration: 13 h and 41 min), inter-rater agreement for identification of behavioural markers was strong. Agreement of RAS-NOTECHS scores indicated moderate to strong agreement. Conclusions RAS-NOTECHS is the first observational tool for multidisciplinary NTS in RAS. In preliminary application, it has been shown to be reliable. Since RAS is rapidly increasing and challenges for effective and safe teamwork remain at the forefront of quality and safety of surgical care, RAS-NOTECHS may contribute to training and improvement efforts in technology-facilitated surgeries.

Thalidomide is a teratogen that affects many organs but primarily induces limb truncations like phocomelia. Rodents are thalidomide resistant. In the 1950s, this has led to misinterpretations of animal tests and to the fatal assumption that the drug was safe for pregnant women to use against morning sickness. The result was one of the biggest scandals in medical history: 10.000 and more infants with birth defects in Europe. Nonetheless, thalidomide still has its place in modern medicine as it has strong therapeutic potential: it has been approved by the FDA for multiple myeloma and erythema nodosum leprosum, and its anti-inflammatory, immunomodulatory and antiangiogenic activities are considered in many other refractory diseases. The aim is to develop derivatives that are not teratogenic but maintain the therapeutic potential. This requires detailed knowledge about the underlying molecular mechanisms. Much progress has been made in deciphering the teratogenic mechanisms in the last decade. Here, we summarize these mechanisms, explain thalidomide resistance of rodents, and discuss possible mechanisms that could explain why the drug primarily targets the developing limb in the embryo. We also summarize the most important therapeutic mechanisms. Finally, we discuss which therapeutic and teratogenic mechanisms do and do not overlap, and if there is a chance for the development of non-teratogenic thalidomide derivatives with therapeutic potential.