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humerus, and proximal radius/ulna. Clinical significance Additional studies are required to determine whether PAUL alters thoracic limb alignment in client-owned dogs.Incorporating virtual human (VH) technology into simulation programs for perioperative education and training can improve interdisciplinary teamwork and communication. The development of VHs allowed interdisciplinary teams at the University of Florida Health Shands Hospital to overcome obstacles during training, such as communication gaps. A multidisciplinary team that included perioperative leaders and quality specialists developed three scenarios for interdisciplinary training to provide participants with the opportunity to practice their communication skills and improve patient safety. Using validated tools to promote standardized communication, participants had to address patient safety concerns assertively during the simulations. After each simulation session, quality specialists conducted a debriefing, collected data via surveys, and identified areas for improvement. As a result of the VH simulation sessions, perioperative staff members reported increased confidence and competence when providing patient care. Using VHs to enhance education is an innovative strategy that is useful for both novice and experienced perioperative nurses.Perioperative personnel with cold sores Key words herpes labialis, herpes simplex virus type 1 (HSV-1), cold sore, infection transmission, surgical mask. Documenting the use of bone wax Key words bone wax, documentation, implant, medical device, electronic health record (EHR). Using sterile surgical skin markers on veins Key words skin marker, isopropyl alcohol, gentian violet, methylene blue, vein. Documenting solutions used to prepare tissue for implantation Key words documentation, preparing tissue, processing tissue, solutions, implantation. Enarodustat Defining fire Key words fire, oxidation, chemical reaction, sentinel event.To foster teamwork, improve clinical excellence, and promote a culture of safety, perioperative leaders should have a clear understanding of the dynamics that affect clinician communication in the OR. We used social network analysis to characterize the typical OR clinician communication patterns at a military surgery center and determine how clinician relationships influenced individual behavior. We surveyed 50 surgical teams and used the data to develop six relational networks and a clinician communication effectiveness index. The study results showed that communication effectiveness increased in networks in which clinicians reported interacting frequently, having close working relationships, socializing, and seeking advice and providing advice to others. Increases in individual clinician centrality were associated with increased communication effectiveness. Participants rated anesthesia professionals as the most effective communicators, followed by perioperative nurses, surgeons, and surgical technologists. Perioperative leaders should consider surgical team familiarity as a potential option to optimize surgical care and improve communication effectiveness.Addressing the increasing shortage of perioperative nurses requires innovative educational strategies. A private university and a teaching hospital with an academic-service partnership collaborated to offer an educational perioperative nursing experience to baccalaureate nursing students to increase student interest in the perioperative nursing specialty. The university offered an elective summer practicum to baccalaureate nursing students between their junior and senior years. After completing the practicum, students had the opportunity to complete their senior-year clinical rotations in the OR. Continuous evaluation contributed to refining the design and implementation of the perioperative nursing practicum. The challenges of the program included cost, demands on staff members' time, and timing of the practicum relative to student and hospital needs. The practicum has been offered for three summers, and a total of six students have enrolled and participated in this program.All patients are at risk for unplanned hypothermia in the perioperative practice setting. Adverse outcomes attributed to hypothermia include myocardial events, surgical site infections, poor wound healing, increased blood loss, and prolonged postanesthesia care unit stays. The AORN "Guideline for prevention of hypothermia" includes recommendations for measuring the patient's body temperature, selecting methods for prevention of unplanned hypothermia, and implementing the selected insulation and warming interventions. This article discusses guideline recommendations related to using a consistent temperature measurement method through all phases of perioperative care, assessing risk for hypothermia in all patients, and prewarming perioperative patients. A scenario provides an example in which an interdisciplinary facility team uses a gap analysis and a risk assessment to determine the process for implementing recommendations from this guideline. Perioperative RNs should review the entire guideline for additional information and for guidance when creating and updating policies and procedures related to unplanned hypothermia.Background Greater than one-half of patients with melanoma who are treated with antibodies blocking programmed cell death protein 1 receptor (anti-PD-1) experience disease progression. The objective of the current study was to identify prognostic factors and outcomes in patients with metastatic melanoma that progressed while they were receiving anti-PD-1 therapy. Methods The authors evaluated 383 consecutively treated patients who received anti-PD-1 for advanced melanoma between 2009 and 2019. Patient and disease characteristics at baseline and at the time of progression, subsequent therapies, objective response rate (ORR), overall survival, and progression-free survival were assessed. Results Of 383 patients, 247 experienced disease progression. The median survival after progression was 6.8 months. There was no difference in survival noted after disease progression based on primary tumor subtype, receipt of prior therapy, or therapy type. However, significantly improved survival after disease progression correlated with clinical features at the time of progression, including normal lactate dehydrogenase, more favorable metastatic stage (American Joint Committee on Cancer eighth edition stage IV M1a vs M1b, M1c, or M1d), mutation status (NRAS or treatment-naive BRAF V600 vs BRAF/NRAS wild-type or treatment-experienced BRAF-mutant), decreasing tumor bulk, and progression at solely existing lesions.