The bacteriology of diabetic foot ulcers and infections and incidence of Staphylococcus aureus Small Colony Variants.

Introduction. Uninfected diabetes-related foot ulcer (DFU) progression to diabetes-related foot infection (DFI) is a prevalent complication for patients with diabetes. DFI often progresses to osteomyelitis (DFI-OM). Active (growing) Staphylococcus aureus is the most common pathogen in these infections. There is relapse in 40-60 % of cases even when the initial treatment at the DFI stage apparently clears infection.Hypothesis. S. aureus adopts the quasi-dormant Small Colony Variant (SCV) state during DFU and consequently infection, and when present in DFI cases also permits survival in non-diseased tissues as a reservoir to cause relapse.Aim. The aim of this study was to investigate the bacterial factors that facilitate persistent infections.Methodology. People with diabetes were recruited from two tertiary hospitals. Clinical and bacterial data was taken from 153 patients with diabetes (51 from a control group with no ulcer or infection) and samples taken from 102 patients with foot complications to identify bacterial species and their variant colony types, and then compare the bacterial composition in those with uninfected DFU, DFI and those with DFI-OM, of whom samples were taken both from wounds (DFI-OM/W) and bone (DFI-OM/B). Intracellular, extracellular and proximal 'healthy' bone were examined.Results. S. aureus was identified as the most prevalent pathogen in diabetes-related foot pathologies (25 % of all samples). For patients where disease progressed from DFU to DFI-OM, S. aureus was isolated as a diversity of colony types, with increasing numbers of SCVs present. Intracellular (bone) SCVs were found, and even within uninfected bone SCVs were present. Wounds of 24 % of patients with uninfected DFU contained active S. aureus. All patients with a DFI with a wound but not bone infection had previously had S. aureus isolated from an infection (including amputation), representing a relapse.Conclusion. The presence of S. aureus SCVs in recalcitrant pathologies highlights their importance in persistent infections through the colonization of reservoirs, such as bone. The survival of these cells in intracellular bone is an important clinical finding supporting in vitro data. Also, there seems to be a link between the genetics of S. aureus found in deeper infections compared to those only found in DFU.

Additive and Non-Additive Effects on the Control of Key Agronomic Traits in Popcorn Lines under Contrasting Phosphorus Conditions.

Phosphorus is a non-renewable natural resource that will run out of reserves in the upcoming decades, making it essential to understanding the inheritance of nutrient use efficiency for selecting superior genotypes. This study investigated the additive and non-additive effects of commercially relevant traits for the popcorn crop (grain yield-GY, popping expansion-PE, and expanded popcorn volume per hectare-PV) in different conditions of phosphorus (P) availability in two locations in Rio de Janeiro State, Brazil. Six S7 lines previously selected for P use-L59, L70, and P7, efficient and responsive; and L54, L75, and L80, inefficient and non-responsive-were used as testers in crosses with 15 progenies from the fifth cycle of intrapopulation recurrent selection of UENF-14, with adaptation to the North and Northwest regions of Rio de Janeiro State. Using the Griffing diallel analysis, P use efficiency was predominantly additive in the expression of PE, and non-additive effects were prominent for GY and PV. For obtaining genotypes that are efficient for phosphorus use, it is recommended that heterosis with parents that provide additive gene accumulation for PE be explored.

Use of Biodegradable Temporising Matrix (BTM) in the reconstruction of diabetic foot wounds: A pilot study.

Introduction: Complex diabetes-related foot wounds are at high risk of infection and subsequent major amputation unless healed expediently. Biodegradable Temporising Matrix (BTM) is a synthetic matrix that facilitates the organisation of the extracellular matrix, resulting in a neodermis layer over these difficult-to-heal areas. The aim of this study was to evaluate the efficacy of using BTM in the reconstruction of challenging diabetic foot wounds. Methods: Eighteen patients with complex diabetic foot wounds (exposed tendon, fascia, joint, bone), or chronic ulcers at high shear stress locations had BTM applied. Indications for BTM application were high shear stress location (66.6%), exposed bone (16.6%), exposed fascia (5.6%), exposed tendon (5.6%) and chronic non-healing wound (5.6%). The time to complete healing, infection rate and incidence of subsequent wound breakdown was analysed. Discussion: Thirteen of 18 patients completed the BTM treatment regime with all these patients achieving complete wound healing at a median time of 13 weeks. One patient had partial treatment with BTM and four patients were withdrawn from the study following BTM application. The rate of infection and re-ulceration were both 15.4%. Conclusion: This is the first prospective cohort pilot study evaluating the use of BTM for complex diabetic foot wounds. BTM demonstrates potential in healing uninfected, non-ischaemic diabetic foot wounds with exposed deep structures and chronic wounds subject to high shear stress. The re-ulceration and infection rates were relatively low for this high-risk population. BTM may also offer promise as an alternative to free flaps. Lay Summary: The prevalence of diabetes and its complications, including foot ulcers and wounds, have significantly increased worldwide over the last 40 years. Increasingly patients are admitted to hospital for antibiotics, debridements and subsequent amputations from these wounds. Complex diabetes-associated wounds are those at highest risk of these complications or necessitating more extensive, complex operations such as free flaps. These wounds may have exposed deep structures, be at risk of high shear stress or be chronic non-healing wounds.Temporisers are a type of material which integrates into the wound and promotes in-growth of tissue, ideal for healing over these difficult to heal areas. Biodegradable Temporising Matrix (BTM) is a synthetic temporising matrix which has demonstrated positive outcomes in facilitating healing in burns and plastics wounds, but its effectiveness in diabetic foot wounds has not yet been proven. This is the first prospective cohort pilot study evaluating the use of BTM for complex diabetic foot wounds. BTM demonstrates potential in healing uninfected, non-ischaemic complex diabetic foot wounds and potentially avoiding more complex operations.

Factors Associated With Key Outcomes in Diabetes Related Foot Disease: A Prospective Observational Study.

OBJECTIVE: Diabetic foot disease is a serious and common complication of diabetes mellitus. The aim of this study was to assess limb and patient factors associated with key clinical outcomes in diabetic patients with foot ulcers. METHODS: This was a prospective observational study of diabetic patients with foot wounds admitted to a major tertiary teaching hospital in South Australia or seen at associated multidisciplinary foot clinics between February 2017 and December 2018. Patient demographic and clinical data were collected, including limb status severity assessed by the WIfI system and grip strength. Participants were followed up for 12 months. The primary outcomes were major amputation, death, amputation free survival, and completion of healing of the index wound within one year. RESULTS: A total of 153 participants were recruited and outcome data were obtained for 152. Forty-two participants underwent revascularisation during the research period. Eighteen participants (11.8%) suffered major amputation of the index limb and 16 (10.5%) died during follow up. Complete wound healing was achieved in 106 (70%) participants. There was a statistically significant association between WIfI stage and major amputation (subdistribution hazard ratio [SHR] 2.75), mortality (hazard ratio [HR] 2.60), amputation free survival (odds ratio [OR] 0.32), and wound healing (SHR 0.69). There was also a statistically significant association between time to healing and grip strength (SHR 0.50), and previous amputations (major or minor) (SHR 0.57). CONCLUSION: This prospective study supports the ability of the WIfI classification system to predict one year key clinical outcomes in a diabetic population with foot ulcers. It also demonstrated that grip strength may be a useful predictor of wound healing.

Assessment of a smartphone-based application for diabetic foot ulcer measurement.

The accurate measurement of diabetic foot ulcer (DFU) wound size is essential as the rate of wound healing is a significant prognostic indicator of the likelihood of complete wound healing. Mobile phone photography is often used for surveillance and to aid in telemedicine consultations. However, there remains no accurate and objective measurement of wound size integrated into these photos. The NDKare mobile phone application has been developed to address this need and our study evaluates its accuracy and practicality for DFU wound size assessment. The NDKare mobile phone application was evaluated for its accuracy in two- (2D) and three-dimensional (3D) wound measurement. One hundred and fifteen diabetic foot wounds were assessed for wound surface area, depth and volume accuracy in comparison to Visitrak and the WoundVue camera. Thirty five wounds had two assessors with different mobiles phones utilizing both applications to assess the reproducibility of the measurements. The 2D surface area measurements by NDKare showed excellent concordance with Visitrak and WoundVue measurements (ICC: 0.991 [95% CI: 0.988, 0.993]) and between different users (ICC: 0.98 [95% CI: 0.96, 0.99)]. The 3D NDKare measurements had good agreement for depth and fair agreement for volume with the WoundVue camera. The NDKare phone application can consistently and accurately obtain 2D measurements of diabetic foot wounds with mobile phone photography. This is a quick and readily accessible tool which can be integrated into comprehensive diabetic wound care.

Evaluation of a Novel Three-Dimensional Wound Measurement Device for Assessment of Diabetic Foot Ulcers.

Objective: The initial wound measurement and regular monitoring of diabetic foot ulcers (DFU) is critical to assess treatment response. There is no standardized, universally accepted, quick, reliable, and quantitative assessment method to characterize DFU. To address this need, a novel topographic imaging system has been developed. Our study aims at assessing the reliability and practicality of the WoundVue® camera technology in the assessment of DFU. Approach: The WoundVue system is a prototype device. It consists of two infrared cameras and an infrared projector, and it is able to produce a three-dimensional (3D) reconstruction of the wound structure. Fifty-seven diabetic foot wounds from patients seen in a multidisciplinary foot clinic were photographed from two different angles and distances by using the WoundVue camera. Wound area, volume, and maximum depth were measured for assessment of reliability. Thirty-one of these wounds also had area calculated by using the established Visitrak™ system, and a correlation between the area obtained by using both systems was assessed. Results: WoundVue images analysis showed excellent agreement for area (intraclass correlation coefficient [ICC]: 0.995), volume (ICC: 0.988), and maximum depth (ICC: 0.984). Good agreement was found for area measurement by using the WoundVue camera and Visitrak system (ICC: 0.842). The average percentage differences between measures obtained by using the WoundVue from different angles for assessment of different sizes and shapes of wounds were 2.9% (95% confidence interval [CI]: 0.3-5.4), 12.9% (95% CI: 9.6-35.7), and 6.2% (95% CI: 2.3-14.7) for area, maximum depth, and volume, respectively. Innovation: This is the first human trial evaluating this novel 3D wound measurement device. Conclusion: The WoundVue system is capable of recreating a 3D model of DFU and produces consistent data. Digital images are ideal for monitoring wounds over time, and the WoundVue camera has the potential to be a valuable adjunct in diabetic foot wound care.

Micronutrient Status in Diabetic Patients with Foot Ulcers.

Objective: To explore the prevalence of micronutrient deficiencies in patients with diabetic foot ulcers and correlate this with foot disease severity and other clinical factors. Approach: Prospective cohort study of diabetic patients with foot ulcers seen in multidisciplinary foot clinics across Adelaide or admitted to the Vascular Surgery Unit at the Royal Adelaide Hospital between February 2017 and September 2018. A total of 131 patients were included in the study. Plasma serum levels of vitamins A, C, D, and E, copper, zinc, and ferritin were measured. Demographic and clinical data, including BMI, smoking status, duration of diabetes, HbA1c, and WIfI score, were obtained. Results: The most prevalent nutritional deficiency found was vitamin D affecting 55.7% of patients. Suboptimal levels of vitamin C affected 73% of patients, comprising marginal levels in 22.2% and deficient levels in 50.8%. Zinc deficiency, vitamin A deficiency, and low ferritin levels were present in 26.9%, 10.9%, and 5.9% of patients, respectively. There was no correlation between BMI, grip strength, duration of diabetes, HbA1c, or smoking status with micronutrient deficiency. Increased severity of diabetic foot disease was associated with lower vitamin C levels (p = 0.02). Innovation: This study has demonstrated that the deficiency of micronutrients, especially vitamin D, vitamin C, zinc, and vitamin A, is common in diabetic patients with foot ulcers. Conclusions: The prevalence of micronutrient deficiency is high in a diabetic population with foot ulcers/wounds. Special concerns regarding the high prevalence of vitamin C and zinc deficiency, given their roles in wound healing. Although further research needs to be performed to determine the clinical implications of our findings, micronutrient deficiency should be considered in diabetic patients with foot wounds.

The patient presenting with chronic limb-threatening ischaemia. Does diabetes influence presentation, limb outcomes and survival?

Peripheral arterial disease (PAD) confers an elevated risk of major amputation and delayed wound healing in diabetic patients with foot ulcers. The major international vascular societies recently developed evidence-based guidelines for the assessment and management of patients with chronic limb-threatening ischaemia (CLTI). CLTI represents the cohort of diabetic and non-diabetic patients who have PAD which is of sufficient severity to delay wound healing and increase amputation risk. Diabetic patients with CLTI are more likely to present with tissue loss, infection and have less favourable anatomy for revascularization than those without diabetes. Although diabetes is not consistently reported as a strong independent risk factor for limb loss, major morbidity and mortality in CLTI patients, it is impossible in clinical practice to isolate diabetes from comorbidities, such as end-stage renal disease and coronary artery disease which occur more commonly in diabetic patients. Treatment of CLTI in the diabetic patient is complex and should involve a multi-disciplinary team to optimize outcomes. Clinicians should use an integrated approach to management based on patient risk assessment, an assessment of the severity of the foot pathology and a structured anatomical assessment of arterial disease as suggested by the Global Vascular Guidelines for CLTI.

SNP-based mixed model association of growth- and yield-related traits in popcorn.

The identification of the genes responsible for complex traits is highly promising to accelerate crop breeding, but such information is still limited for popcorn. Thus, in the present study, a mixed linear model-based association analysis (MLMA) was applied for six important popcorn traits: plant and ear height, 100-grain weight, popping expansion, grain yield and expanded popcorn volume per hectare. To this end, 196 plants of the open-pollinated popcorn population UENF-14 were sampled, selfed (S1), and then genotyped with a panel of 10,507 single nucleotide polymorphisms (SNPs) markers distributed throughout the genome. The six traits were studied under two environments [Campos dos Goytacazes-RJ (ENV1) and Itaocara-RJ (ENV2)] in an incomplete block design. Based on the phenotypic data of the S1 progenies and on the genetic characteristics of the parents, the MLMA was performed. Thereafter, genes annotated in the MaizeGDB platform were screened for potential linkage disequilibrium with the SNPs associated to the six evaluated traits. Overall, seven and eight genes were identified as associated with the traits in ENV1 and ENV2, respectively, and proteins encoded by these genes were evaluated for their function. The results obtained here contribute to increase knowledge on the genetic architecture of the six evaluated traits and might be used for marker-assisted selection in breeding programs.

Genetic effects on the efficiency and responsiveness to phosphorus use in popcorn as estimated by diallel analysis.

Agricultural expansion and the need for sustainable cultivation are challenges faced by researchers involved in the generation of new cultivars that can adapt to abiotic stress. Knowledge of the genetic effects of characteristics related to efficiency and responsiveness to phosphorus use must be considered when implementing methods to obtain better genotypes. The aim of this study was to characterize and select popcorn hybrids based on their efficiency and responsiveness to phosphorus use, and estimate their combining abilities and genetic effects via diallel analysis to implement improvement programs for sustainable agriculture. Eight contrasting inbred lines were used to obtain simple hybrids for diallel analysis. Twenty-eight diallelic hybrids plus the popcorn parental lines were evaluated at two different sites under two contrasting environments for soil phosphorus availability (6 × 6 lattice design). Grain yield, popping expansion, and volume of expanded popcorn per hectare were measured. A combined analysis of variance and a test of means were performed. The classification and utilization of the phosphorus use efficiency index, according to the grain yield performance of the hybrids under contrasting environments, was considered. Through model 2 of the Griffing's diallel analysis method, the general and specific combining abilities were estimated, along with their environmental interactions. The best strategy to obtain genotypes that are efficient and responsive to phosphorus involves exploring popcorn hybrids using genitors that result in the accumulation of additive genes that promote popping expansion. Hybrids P7 × L80, P7 × L59, P7 × L76, and P6 × L80 presented promising results and may be evaluated as cultivation options in phosphorus-deficient soils.

Low total psoas area as scored in the clinic setting independently predicts midterm mortality after endovascular aneurysm repair in male patients.

OBJECTIVE: Preoperative sarcopenia is an established risk factor for poor outcomes after surgery. Methods for assessing sarcopenia are either complex, time consuming, or poorly validated. We aimed to assess the interobserver reliability of scoring psoas area at the level of the L3 vertebra and to evaluate whether sarcopenia scored by this simple and rapid method correlated with other fitness scoring methods or impacted on mortality and duration of stay for patients undergoing endovascular aneurysm repair (EVAR). METHODS: We had access to 191 preoperative computed tomography scans of patients who underwent EVAR. For each scan the axial slice at the most caudal level of the L3 vertebra was extracted. Three observers independently calculated the combined cross-sectional area of the left and right psoas muscle at this level. Interobserver variability was calculated as per Band and Altman. Psoas area was normalized for patient height with sarcopenia defined as total psoas area of <500 mm2/m2. The effect of sarcopenia on patient survival was assessed using Cox proportional hazards models. Kaplan-Meier curves are also presented. RESULTS: Interobserver reliability of scoring psoas area was acceptable (reproducibility coefficient as percent of mean for each observer pair: 7.92%, 7.95%, and 14.33%). Sarcopenic patients had poorer survival (hazard ratio, 2.37; P = .011) and an increased hospital duration of stay (4.0 days vs 3.0 days; P = .008) when compared with nonsarcopenic patients. Sarcopenic patients were more likely to self-report as unfit (12.4% vs 33.3%; P = .004). Sarcopenia did not correlate with an increased rate of postprocedure complications. CONCLUSIONS: Psoas area scoring has good interobserver reliability. Preoperative sarcopenia as defined by psoas area was associated with poorer survival and of longer length of stay. As all patients being worked up for an endovascular aortic aneurysm repair will undergo a computed tomography scan, this method is a rapid and effective way to highlight patients in the clinic setting who have an increased risk of morbidity and mortality after EVAR.

What are the demographic predictors in laparoscopic simulator performance?

BACKGROUND: Simulation is playing an increasingly important role in surgical education. There are a number of laparoscopic simulators of which the design and tasks vary considerably. It is unknown if any particular type may result in better outcomes for a specific population. This study assesses the predictors of acquisition of basic surgical skills on two different laparoscopic simulators. METHODS: Participants (n = 370) were randomized to be trained and assessed using either a fundamentals of laparoscopic surgery (FLS) or a LapSim (Surgical Science, Goteborg, Sweden) simulator. The number of attempts required to reach proficiency on individual tasks and on each simulator was recorded and compared with demographic data and surgical experience. RESULT: Skills acquisition on both simulators was positively affected by surgical experience. Gender was an influential factor on the LapSim with men reaching proficiency sooner than women. The effect of gaming had no clear influence on the participants' scores; however, for those who reported more than 1 h/week gaming, it had a positive influence on skills acquisition on the FLS and a negative influence on the LapSim. Playing a musical instrument had no impact. Practising non-surgical tasks requiring manual dexterity and handedness were not an influential factor in total proficient scores, but had a significant impact on individual task scores on the FLS simulator. CONCLUSIONS: The rate of skills acquisition on each simulator and individual tasks are influenced by different demographic characteristics of the participants. This has implications for surgical education as it may inform the selection of the most suitable laparoscopic simulators for specific populations of trainees.

Mobile Simulation Unit: taking simulation to the surgical trainee.

BACKGROUND: Simulation-based training has become an increasingly accepted part of surgical training. However, simulators are still not widely available to surgical trainees. Some factors that hinder the widespread implementation of simulation-based training are the lack of standardized methods and equipment, costs and time constraints. We have developed a Mobile Simulation Unit (MSU) that enables trainees to access modern simulation equipment tailored to the needs of the learner at the trainee's workplace. METHODS: From July 2012 to December 2012, the MSU visited six hospitals in South Australia, four in metropolitan and two in rural areas. Resident Medical Officers, surgical trainees, Fellows and International Medical Graduates were invited to voluntarily utilize a variety of surgical simulators on offer. Participants were asked to complete a survey about the accessibility of simulation equipment at their workplace, environment of the MSU, equipment available and instruction received. Utilization data were collected. RESULTS: The MSU was available for a total of 303 h over 52 days. Fifty-five participants were enrolled in the project and each spent on average 118 min utilizing the simulators. The utilization of the total available time was 36%. Participants reported having a poor access to simulation at their workplace and overwhelmingly gave positive feedback regarding their experience in the MSU. CONCLUSION: The use of the MSU to provide simulation-based education in surgery is feasible and practical. The MSU provides consistent simulation training at the surgical trainee's workplace, regardless of geographic location, and it has the potential to increase participation in simulation programmes.

Nontechnical skills training for the operating room: A prospective study using simulation and didactic workshop.

BACKGROUND: The best surgeons demonstrate skills beyond those required for the performance of technically competent surgery. These skills are described under the term nontechnical skills. Failure in these domains has been associated with adverse events inside the operating room. These nontechnical skills are not learned commonly in a structured manner during surgery training. The main purpose of this study was to explore the effects of participation in simulation-based training, either as a sole strategy or as part of a combined approach on surgeons and surgical trainees nontechnical skills performance in simulation environment. METHODS: The study consisted of a single-blinded, prospective comparative trial. Forty participants were enrolled, all participating in 2 simulation sessions challenging nontechnical skills comprising 3 surgical scenarios. Seventeen participants attended a 1-day, nontechnical skills workshop between simulation sessions. Scenarios were video-recorded for assessment and debriefing purposes. Assessment was made by 2 observers using the Non-Technical Skills for Surgeons (NOTSS) scoring system. RESULTS: There was a significant improvement in nontechnical skills performance of both groups from the first to the second simulation session, for 2 of the 3 scenarios. No difference in performance between the simulation and the simulation plus workshop groups was noted. CONCLUSION: This study provides evidence that formal training in nontechnical skills is feasible and can impact positively participants' nontechnical performance in a simulated environment. The addition of a 1-day didactic workshop does not seem to provide additional benefit over simulation-based training as a sole strategy for nontechnical skills training.

Effect of peritoneal cavity lavage with 0.9% and 3.0% saline solution in the lung and spleen of gerbils with induced peritonitis.

BACKGROUND: Peritoneal cavity lavage is used widely in the treatment of peritonitis. Nonetheless, some studies question its rationale and prove it to be deleterious to the mesothelium. The present study aims to determine whether 0.9% and 3.0% saline lavage of the peritoneal cavity have an effect on the early systemic inflammatory response, namely, in the lung injury and splenic cellularity of gerbils with induced peritonitis. METHODS: Thirty-four male gerbils were divided into four groups: Control (n=9), submitted to laparotomy at time zero, re-laparotomy after 2 h, and sacrificed after a total of 6 h from start; untreated (n=8), submitted to peritonitis induction through cecal ligation and puncture (CLP) at time zero, re-laparotomy intended for drying of abdominal cavity and resection of the ischemic cecum after 2 h, and sacrifice after a total of 6 h from start; saline (n=8), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm 0.9% saline lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start; and hypertonic (n=9), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm hypertonic saline (3.0%) lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start. After sacrifice, we collected the left lung and the spleen for morphometric analysis. RESULTS: In the both the saline and hypertonic groups, there was significant decrease in the mean nuclei count in the lungs, compared with the untreated group (p<0.01). There was no difference in terms of nuclei count in the spleen among groups (p>0.05). CONCLUSIONS: The present study demonstrated that the peritoneal lavage with large volumes of warm 0.9% and 3.0% saline has a beneficial effect on the early systemic inflammatory response in infected animals, modulating and reducing the lung injury but having no effect on splenic cell count.

Multidisciplinary team simulation for the operating theatre: a review of the literature.

INTRODUCTION: Analyses of adverse events inside the operating theatre has demonstrated that many errors are caused by failure in non-technical skills and teamwork. While simulation has been used successfully for teaching and improving technical skills, more recently, multidisciplinary simulation has been used for training team skills. We hypothesized that this type of training is feasible and improves team skills in the operating theatre. METHODS: A systematic search of the literature for studies describing true multidisciplinary operating theatre team simulation was conducted in November and December 2012. We looked at the characteristics and outcomes of the team simulation programmes. RESULTS: 1636 articles were initially retrieved. Utilizing a stepwise evaluation process, 26 articles were included in the review. The studies reveal that multidisciplinary operating theatre simulation has been used to provide training in technical and non-technical skills, to help implement new techniques and technologies, and to identify latent weaknesses within a health system. Most of the studies included are descriptions of training programmes with a low level of evidence. No randomized control trial was identified. Participants' reactions to the training programme were positive in all studies; however, none of them could objectively demonstrate that skills acquired from simulation are transferred to the operating theatre or show a demonstrable benefit in patient outcomes. CONCLUSION: Multidisciplinary operating room team simulation is feasible and widely accepted by participants. More studies are required to assess the impact of this type of training on operative performance and patient safety.