The UEMS experience in continuous medical education accreditation process: a 'quo vadis' analysis of our global database.

Background: The authors systematically appraise a large database of continuous professional development (CPD) and continuous medical education (CME) events against the European Accreditation Council for Continuous Medical Education (EACCME) framework. Methods: The authors performed a retrospective observational study of all CPD or CME events within the European Union of Medical Specialists (UEMS) database between 2017 and 2019, including 91 countries and 6034 events. Assessment of event design, quality and outcomes was evaluated against a validated, expert-derived accreditation framework, using thematic analysis to extract distinct themes, and subsequent quantitative analysis. Results: The authors included 5649 live educational events (LEEs) and 385 e-learning materials (ELMs). Three thousand seven hundred sixty-two [3762 (62.3%)] of the events did not report clear justification in their needs assessment process. Most accreditation applications claimed covering a single educational need [1603/2277 (70.3%)]. Needs assessments were reported to be similar across conferences, courses and other types of events (P<0.01); 5642/6034 events (93.5%) had clearly documented expected learning outcomes; only 978/6034 (16.2%) reported a single expected learning outcome while the rest report 2-10 outcomes. Providers who declared more than one educational need also declared multiple learning outcomes (ρ=0.051, P<0.01). Conclusions: Despite EACCME providing a robust framework for the CPD/CME accreditation process, reporting quality can still be improved, as more than 1 in 2 events fail to provide a clear description of their needs assessment. To the authors' knowledge, this is the largest educational LEE/ELM database, which can be a starting to revisit the CME/CPD accreditation process.

Comparison of criteria for elective tracheostomy in head and neck cancer surgery.

OBJECTIVES: Elective tracheostomy before resection of a malignancy in head and neck region assures unobstructed ventilation during postoperative period but is associated with an increased risk of complications. We aimed to evaluate retrospectively, how application of elective tracheostomy scales would influence frequency of tracheostomy in comparison with preoperative clinical judgement. METHODS: In 205 patients operated from 2013 till 2017 resection of a malignancy involved suprahyoid or pharyngeal muscles, neck dissection and flap reconstruction. Elective tracheostomy decision was made on clinical basis. Score for each patient in 3 published scales has been calculated. RESULTS: In the study group 76 patients had an elective tracheostomy at the outset of a resection procedure. Among 129 patients without elective tracheostomy 9 had a tracheostomy in postoperative period. Indications for elective tracheostomy were calculated for scale I, II and III. Only in 120 patients the decision to perform elective tracheostomy or not would be identical in each scale. CONCLUSION: Our results suggest that decisions to perform an elective tracheostomy based on the 3 scales has low specificity. The factors used in the published scales should be evaluated in a prospective multicenter study.

Gait changes in patients after reconstruction of facial bones with fibula and iliac crest free vascularized flaps.

PURPOSE: Patients with malignant tumours of the oral cavity require its surgical removal and reconstruction of the bone and soft tissues. The grafts are obtained either from leg (fibula) or pelvis (iliac crest). The removal of grafts from the locomotor apparatus can impair the gait. The aim of this study was to find out how the localization of donor site influences the gait pattern. METHODS: Results obtained for 30 patients were analyzed (16 fibula graft, 14 iliac crest graft). Patients underwent instrumented gait analyses three times (VICON system): before surgery, 2-4 month after the surgery, and 4-8 months after the surgery. RESULTS: In both groups several gait parameters were changed. Two parameters changed in both groups: gait speed and cadence. In patients receiving iliac crest graft the changed gait variables were: pelvic rotation, hip range in sagittal plane (operated side), knee range in sagittal plane (operated side), foot dorsiflexion in swing on both sides. In patients receiving fibula flap the changed gait variables were: tilt, range motion of the tilt, minimum hip flexion (operated side), time to maximum knee flexion (non-operated side), GGI (non-operated side) and step length (nonoperated side). CONCLUSIONS: The primary gait deviations occurring after surgery, and the compensatory mechanisms which subsequently arise depend on the localization of graft donor site. The results indicate that the patients in whom fibula flap was used have less problems with gait pattern after the surgery than the patients receiving iliac crest graft.

Surgical Techniques for Closure of a Scalp Defect After Resection of Skin Malignancy.

BACKGROUND: Surgery for scalp malignancies is aimed at the complete resection and a good aesthetic outcome. The goal was to develop an algorithm for scalp reconstruction based on the authors' surgical experience. METHODS: This is a retrospective analysis of 123 procedures of scalp malignancies in 105 patients. Twenty eight procedures were for resection of squamous cell carcinoma, 54 for basal cell carcinoma, and 41 for suspected melanomas. RESULTS: Primary closure (27 procedures), local flap (LF; 19), split-thickness skin graft (SG; 64), rotated LF and SG (9), and free vascularized flaps (4) were used. Complications were partial (4) and total (1) necrosis of SG, free-flap atrophy (1), infection (2), wound dehiscence (1), and death due to cardiovascular complications (1). During follow-up, recurrence occurred in 22 patients (21%) and metastases to lymph nodes in 3 (3%). CONCLUSION: Surface area size and the presence of the periosteum as well as a bone infiltration are important factors that can guide selection of a reconstruction method after resection of scalp malignancy.

Vasculature of a Medial Femoral Condyle Free Flap in Intact and Osteotomized Flaps.

BACKGROUND: A small size and difficulties with shaping a medial femoral condyle corticocancellous bone flap are factors limiting its use. The goal of this study was to evaluate range of vascular supply to a medial femoral condyle corticocancellous bone flap to determine whether harvesting of larger flaps and performing a flap osteotomy would compromise the vasculature of a flap's bone. METHODS: Twenty-four limbs were dissected and medial femoral condyle corticocancellous bone flaps were harvested with skin paddles. Thirteen of 24 flaps had subperiosteal osteotomies simulating shaping a bone for reconstruction. A pedicle artery was perfused with red latex. Medial femoral condyle corticocancellous bone flap vascularization was evaluated by cutting the bone into 1-cm blocks and assessing the number of Haversian canals filled with red latex. RESULTS: Length of harvested flaps was 7 to 13 cm, thickness was 0.5 to 3 cm, and width was 1 to 3 cm. Pedicle length was between 3.5 and 9 cm (mean ± SD, 6.6 ± 1.6 cm). Red latex filled bone vessels at a distance of 6 to 11.5 cm from the distal end of a flap (8.2 ± 1.4 cm). Skin paddles were filled with latex in all cases. CONCLUSION: A medial femoral condyle corticocancellous bone flap had sufficient blood supply, allowing for harvesting flaps up to 11 cm long, and subperiosteal osteotomy did not compromise the vasculature of the flap's bone.

Mutational Analysis of Recurrent Meningioma Progressing From Atypical to Rhabdoid Subtype.

BACKGROUND: Rhabdoid meningioma is rare aggressive meningioma histological subtype that develops predominantly through progression from less malignant tumors. Owing to its low incidence, this tumor's biological background is unknown. The aim of this study was to profile somatic mutations in 4 meningioma samples from the same patient, derived previously from 4 subsequent tumor resections. CASE DESCRIPTION: A 58-year-old woman presented with recurrent meningioma progressing from atypical to rhabdoid subtype. Four tumor samples that represent a primary tumor (atypical GII) and 3 recurrent tumors that were subsequently removed (anaplastic GIII, rhabdoid GIII, and anaplastic/rhabdoid GIII) from this patient were subjected to mutational analysis of coding sequences of 952 tumor-related genes. Three mutations were identified in all tumor samples exhibiting a high allelic frequency: ARID1A frameshift deletion, NF2 in-frame deletion, and missense variant of SRSF2. The predicted inactivating effect of ARID1A deletion was confirmed by immunohistochemical staining of tumor sections in which a high proportion of cells lacked protein expression. Additional low-allelic-fraction mutations were observed in all tumor samples, likely representing "passenger," low-effect mutations that reflect a clonal selection of tumor cells through malignant progression of the meningioma. CONCLUSION: The mutation of ARID1A that encodes the subunit of the SWI/SNF complex represents the most likely driver of the tumor's malignant potential. It also may be involved in the acquisition of the rhabdoid phenotype, given that mutations in chromatin remodeling proteins are the hallmark of atypical teratoid/rhabdoid tumors.

Hypofractionated accelerated radiotherapy in T1-3 N0 cancer of the larynx: A prospective cohort study with historical controls.

AIM: The goal of this prospective study was to assess the effectiveness of a hypofractionated accelerated regime in treatment of the larynx cancer. BACKGROUND: Multiple radiotherapy delivery regimes are used for treatment of the larynx cancer. Hypofractionated regimes could provide similar results with reduced use of radiotherapy facilities. MATERIAL AND METHODS: 223 patients with squamous cell carcinoma of the upper or middle larynx have been treated with 63 Gy delivered in 28 fractions of 2.25 Gy during 38 days, 5 fractions per week. The study endpoints were overall survival, progression-free survival, early and late treatment toxicity. Standard and accelerated radiotherapy groups from the study published by Hliniak et al.20 served as controls. RESULTS: Five-year actuarial overall survival was 87.5% in the study group, 84.5% in the control group receiving accelerated radiotherapy (33 fractions of 2.0 Gy, 6 fractions per week) and 86.2% in the control group (33 fractions of 2.0 Gy, 5 fractions per week). Five-year progression-free survival was 73.6%, 77.2% and 66.2%, respectively. Overall, treatment toxicity and complication rates did not differ between the study group and the control groups. CONCLUSIONS: The hypofractionated accelerated radiotherapy protocol using 5 fractions per week reduced the use of radiotherapy facilities. There was no significant difference in overall survival and progression-free survival between the study and control groups treated with accelerated or standard radiotherapy.

[Etiology of infection associated with neoplastic changes of organs in the head and neck in patients hospitalized in the Oncology Centre in Warsaw].

INTRODUCTIONS: According to clinical observations primary neoplastic lesions in the head and neck are often complicated by infection. The incidence of postoperative complications of cancer lesions of the head and neck, oral cavity, upper airways or larynx is from 19% up to 47% cases but in extensive and long-term operations can reach 80%. METHODS: We retrospectively evaluated results of microbiological investigations of 312 clinical specimens collected from patients from Clinical Head and Neck Cancers of On- cology Center in Warsaw in the years 2008 -2012. All samples of clinical materials were plated on the suitable culture media and incubated according to the recommendations. RESULTS: The study has shown that from all collected clinical specimens 491 strains have been isolated. Nearly half of the cultured bacteria were Gram-positive cocci (48.7%), mainly methicillin-sensitive Staphylococcus aureus. Most Gram-negative bacteria isolated from neoplastic lesions in the head and neck belong to Enterobacteriaceae (21%), 23,4% of cultured bacteria grown anaerobically and they were mainly Gram-negative rods. CONCLUSIONS: The presence of diverse bacterial flora colonizing the mucous membranes of the mouth and throat may be the reason of difficulties in interpretation of microbiological investigation. It must be remembered that knowledge of colonizing and pathogenic flora of the area of head and neck enables appropriate preoperative prevention and empiric therapy.

Tissue response after implantation of pure titanium and bioresorbable screws in scapula with postoperative irradiation: an experimental study on rats.

OBJECTIVE: The study focuses on the comparison of tissue reaction to titanium and bioresorbable implants with and without postoperative irradiation on an animal model. MATERIALS AND METHODS: Thirty-nine LEW/W rats were randomly assigned to experimental or control groups. One titanium and one bioresorbable screw (poly-L-lactide [PLLA] and L- and D-lactide poly-L/D-lactide [PDLLA]) were implanted into the left scapulas of 24 rats. Half of them received 30 Gy to the operation site and the other half received 42 Gy. In the control groups, 3 rats received 30 Gy, and 6 rats received 42 Gy to the scapula area without operation; and 6 rats had implants inserted as in the experimental group, but received no postoperative irradiation. The scapulas were removed 14 or 30 days after irradiation and a histologic analysis was performed. RESULTS: The host tissue reaction to titanium and PLLA-PDLLA screws without postoperative irradiation was of similar intensity. In irradiated animals, the inflammatory tissue reaction was more evident around the titanium screws than around the bioresorbable screws, irrespective of the radiation dose and of the time that elapsed from the irradiation. The reaction was more evident on the 14th day than on the 30th day after the last radiation dose (70 and 86 days after surgery, respectively). The intensity of the inflammatory tissue reaction, irrespective of the implant type, was more intense in the group irradiated with 42 Gy. CONCLUSIONS: PLLA-PDLLA implants appear to cause less tissue reaction after irradiation and could be safer reconstructive devices than titanium implants for patients undergoing surgery and adjuvant radiotherapy for cancer.

Follow-up in patients treated for head and neck cancer.

Principles of follow-up management in patients treated for head and neck tumors are not very strictly defined, and practice varies between countries, centers, and specialists. Details of follow-up procedures, including timing of outpatient visits and diagnostic imaging, are specific for tumor types and localizations but also depend on treatment modalities used, availability of diagnostic procedures, and socioeconomic factors. The authors describe general principles of follow-up in head and neck cancer patients. Clinical observation and laboratory and imaging studies in patients who had received radical treatment should focus on early identification of recurrent or second primary tumors to allow for a salvage radical therapy. In patients who initially had received a palliative care, the follow-up should focus on proper management of symptoms.

Leiomyosarcoma of the external ear--case report.

In head and neck region leiomyosarcoma is a very rare finding. This tumor is usually located in abdominal cavity. We report a case of 78-year-old man with tumor of the auricle that was resected with 0.7 cm margin. Histological and immunohistochemical analysis revealed the leiomyosarcoma. Adjuvant therapy was not advised. During 3 years of follow-up there are no signs of recurrence. Review of the literature shows that the survival of patients with leiomyosarcoma in head and neck region seems to be similar to other kinds of sarcomas in this localization. It is not clear, how large surgical margins should be to achieve satisfactory local control.

Contamination of the surgical field in head and neck oncologic surgery.

BACKGROUND: The purpose of this study was to determine the timing and type of surgical field contamination in 50 consecutive resections for advanced head and neck cancer with same-stage tissue reconstruction and to analyze the relationship between contamination and the surgical site infection. METHODS: Swabs from the surgical field and from surgical drapes close to the field were taken every 2 hours (at 0 hour, 2 hours, 4 hours, and 6 hours) and sent for a standard microbiological diagnostic procedure. Results were recorded in Microsoft Excel and analyzed with SPSS. RESULTS: We collected 336 swabs of which 71% were contaminated. Polymicrobial contamination was observed in 153 samples (45%). Twenty-six species of pathogens were found, the most frequent was Streptococcus species. Surgical site infection with positive culture occurred in 3 patients. CONCLUSION: In head and neck surgery for advanced cancer, standard aseptic procedures do not prevent contamination of the surgical field with physiological bacterial flora of the skin and oral cavity. Although contamination was common, surgical site infection was rare.

Quiz. Correct answer to the quiz. Check your diagnosis. Mesenchymal chondrosarcoma of the orbit: two cases and a brief review of the literature.

Mesenchymal chondrosarcoma (MChS) is a rare, high-grade malignant tumor which occurs both in the bone and soft tissue. The extraskeletal location comprises one third of all MChS and in review of the up-to-date literature, about 30 cases of the orbital involvement were found. The authors present clinical, radiological and pathological findings of two cases of MChS of the orbit occurring in young adult females: primary extraskeletal MChS of the orbit and skeletal MChS of the ethmomaxillary complex with secondary orbit involvement. The histopathological examination revealed a characteristic biphasic pattern composed of small round to spindle-shaped cells, mimicking Ewing sarcoma family of tumors, with areas of a haemangiopericytoma-like pattern and admixed cartilage foci. One of the patients had local recurrence 3 years after initial surgical removal. Subsequently, she underwent enucleation followed by chemotherapy. The other patient had a biopsy and debulking resection of the tumor and started chemotherapy. Ten months follow-up of this patient show no evidence of metastasis.

[Anatomy and surgical approaches to the parapharyngeal space]. / Anatomia i dostepy chirurgiczne do przestrzeni przygardlowej.

PURPOSE: Analysis of surgical approaches to primary tumors localized in parapharyngeal space used in Head & Neck Cancer Department, Cancer Center Institute in Warsaw. Description of differences in terminology used to describe fascial compartments of the neck. MATERIAL AND METHODS: Retrospective analysis of medical records of 8 selected patients who had an operation for primary parapharyngeal space neoplasm. Analysis has been done of operation protocols, diagnostic images, tumor size and histopathology. RESULTS: Transcervical, transparotid and transmandibular approaches were used with additional rhinotomy and craniotomy in selected cases. Selection of approach should take into account tumor localization, its size and histopathology. CONCLUSIONS: Planning of surgical procedure for parapharyngeal space tumor should be based upon analysis of diagnostic images and selection of the approach depends on tumor localization, size and histopathology. Differences in terminology of superficial and middle cervical fascial compartments can lead to inappropriate clinical decisions.

Perioperative problems and treatment of a teenager with a juvenile angiofibroma refusing blood transfusion.

OBJECTIVES: Juvenile angiofibroma is a benign, non-encapsulated neoplasm, consisting of vascular and connective tissue. Its main feature is a local malignancy. In its clinical course it destroys adjoining structures, without metastasizing. It appears rarely, and is mainly found in boys at puberty. Among theories about the aetiology of juvenile angiofibroma, we must consider a haematoma-like lesion, an angioma with an extended fibrous component, or type of inflammatory allergic polyp. In the development of the lesion the participation of hormonal disorders on the pituitary gland-gonad axis is also suggested. According to the latest research, juvenile angiofibroma is regarded as a developmental defect, affecting the embryonic vascular network surrounding the sphenoid bone. METHODS: If the patient or his/her parents refuse blood transfusion and use of blood products, it is necessary to apply modifications in the routine perioperative treatment. In the case of the patient refusing blood and blood products transfusion because of their beliefs, it is possible to get consent to use different, highly processed products like albumins or a cryoprecipitate, as well as applying some blood-saving techniques. CONCLUSIONS: 1. Removal of juvenile angiofibroma with minimal bleeding is possible. 2. Applying erythropoietin and iron preparations prior to surgery increases erythropoiesis and reduces the risks in transfusion. 3. Applying intraoperative normovolaemic haemodilution is a safe method and allows avoidance of transfusion of blood-derived products.

[Can we get rid of hospital infections in head and neck surgery?]. / Czy mozna wyeliminowac zakazenia szpitalne w chirurgii nowotworów glowy i szyi?

Infection rate registered on the basis of clinical symptoms and of microbiological forms in patients treated in Surgery Division, Head & Neck Cancer Department during 2001-2003, was analyzed. Total number of patients treated was 2343. In 664 preoperative microbiological cultures have been obtained from suspected areas and in 52.8% of these a pathogen has been found. Patients undergoing major surgery received a prophylactic antibiotic selected by an infection control team and Microbiology Department. If preoperative cultures showed resistance to standard prophylactic antibiotic, another was selected on the antibiogram basis. Particular attention was paid to all the elements of prophylactic against infection in the ward, examination and dressing rooms, operating theatre. In 48% of patients, mainly those after extensive, prolonged surgery, antibiotics (usually 3rd generation cephalosporins) were used for 5-7 days. During 2001, 2002 and 2003 correspondingly 148, 97 and 58 infections were registered with positive culture and infection with clinical symptoms occurred in 30, 21 and 20 patients (4%, 2,8% i 2,3%). Comparisons of hospital infection rates between different institutions are very difficult, but relatively low rate in our material and decreasing number of infections registered during consecutive years show that persistent and multifaceted prophylactic interventions can result in significant reduction of hospital infections also in patients wits contaminated surgical field.

[Cancer in branchiogenic cyst--primary focus or metastasis?]. / Rak w obrebie torbieli bocznej szyi--proces pierwotny czy przerzut?

The authors report the case of 68 year old male operated upon for the branchial cyst of the neck. Histopathological examination showed carcinoma in the wall of the cyst. Ipsilateral tonsillectomy was done and pathology revealed primary focus in the palatine tonsil. Diagnosis of the branchiogenic cancer should be made only when all the criteria defined by Martin in 1950 are met. Patients with carcinoma cells found in branchial cyst should be diagnosed and treated as metastasis from Waldeyer's ring to the lymph nodes of the neck. Ipsilateral tonsillectomy is indicated as blind biopsy. When histopathological examination of the tonsil is negative the patients should be treated as metastasis to the neck from unknown primary focus.

[Skull base surgery techniques in the treatment of pituitary adenomas]. / Zastosowanie technik chirurgii podstawy czaszki w leczeniu gruczolaków przysadki.

The giant pituitary adenoma surgery remains a real challenge to any neurosurgeon. Despite an extensive development of transsphenoidal techniques, open craniotomy procedures still are required in 5-10% of all cases with pituitary adenoma. The skull base surgery techniques not only allow to minimize the surgery-related trauma of the brain, but also improve the access to the operating field. In the years 1998-2001 the authors operated on the total of 395 pituitary adenoma patients, mostly using the transsphenoidal approach (320 cases), with skull base surgery techniques applied in 75 cases (i.e. in 19% of all patients)--in 67 patients the transbasal-subfrontal approach was applied, and in 2 cases--lateral rhinotomy. There were two indications to the transbasal-subfrontal approach: a large size of the tumor causing visual disturbances, and extension of the adenoma to adherent anatomical spaces. In this group of patients the total removal of the tumour was achieved in 88% of cases. In the remaining patients remnants of the tumor were left in the cavernous sinuses. The skull base surgery techniques are most useful in the treatment of selected patients with pituitary adenoma.