European OMFS in the time of Brexit - where did the UK fit and how might the future look?

INTRODUCTION: The specialty of OMFS in the UK is a dual degree specialty which was recognised in Europe within Annex V of Directive 2005/36/EU. Currently UK law matches that of the EU. Brexit may change this. DIRECTIVE 2005/36/EU: Defines two specialties within European nations, Dental, Oro-Maxillo-Facial Training DOMFS (Basic dental & medical training) and Maxillofacial Surgery (basic medical training). The UK sat within DOMFS and so specialists from DOMFS nations could travel and work in the UK. Specialists from all other nations were required to use the Certificate of Eligibility for Specialist Registration (CESR) route. DIRECTIVE 2013/55/EU: This directive updated 2005/36/EU regarding Mutually Recognised Professional Qualifications (MRPQ) including creating an international alert system for doctors in difficult Entry onto the UK OMFS Specialist List by CESR Route CESR application is a large and complex portfolio of evidence to demonstrate knowledge, skills and experience are equivalent to a Certificate of Completion of Training (CCT) holder. To date, no EU applicants have successfully completed a CESR application. UNION OF EUROPEAN MEDICAL SPECIALISTS (UEMS): Even after Brexit, the UK will remain a full member of UEMS. The OMFS Section of UEMS is a source of information and support for specialists wishing to work in other nations and for nations wishing to develop an OMFS specialty in their nation. ACCESS TO UK OMFS TRAINING FOR NON-UK TRAINEES: Applicants meeting the person specifications for approved OMFS specialty training (ST) posts in the UK are welcome to apply to the national selection process for OMFS specialty training in the UK. Many have done so successfully. Fixed term appointments and Fellowships are advertised and represent a useful route to gain support for application for training or through the CESR Route. CONCLUSIONS: The UK remains part of the diverse OMFS community in Europe. There is support from within the UK and from UEMS for trainees and specialists interested in coming to the UK to train or to work.

Virtual ARCP assessment and trainee feedback meetings: facilitating the best experience and practice.

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not 'business as usual', although colleagues accept this form of communication as the new norm. In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely. This form of communication has some advantages but may also present possible barriers for feedback and development particularly for 'trainees in difficulty' when there are concerns about progression, and when an unsatisfactory outcome has been awarded. It is also worth remembering that there may be generational differences with the ease of use of virtual meeting platforms. We present some of the important factors for optimising the panel of virtual ARCPs and discuss methods to improve feedback given remotely for trainees.

Meeting report from the joint IARC-NCI international cancer seminar series: a focus on colorectal cancer.

Despite significant progress in our understanding of the etiology, biology and genetics of colorectal cancer, as well as important clinical advances, it remains the third most frequently diagnosed cancer worldwide and is the second leading cause of cancer death. Based on demographic projections, the global burden of colorectal cancer would be expected to rise by 72% from 1.8 million new cases in 2018 to over 3 million in 2040 with substantial increases anticipated in low- and middle-income countries. In this meeting report, we summarize the content of a joint workshop led by the National Cancer Institute and the International Agency for Research on Cancer, which was held to summarize the important achievements that have been made in our understanding of colorectal cancer etiology, genetics, early detection and treatment and to identify key research questions that remain to be addressed.

Can digital breast tomosynthesis perform better than standard digital mammography work-up in breast cancer assessment clinic?

PURPOSE: To compare the efficacy of use of digital breast tomosynthesis (DBT) with standard digital mammography (DM) workup views in the breast cancer assessment clinic. MATERIALS AND METHODS: The Tomosynthesis Assessment Clinic trial (TACT), conducted between 16 October 2014 and 19 April 2016, is an ethics-approved, monocenter, multireader, multicase split-plot reading study. After written informed consent was obtained, 144 females (age > 40 years) who were recalled to the assessment clinic were recruited into TACT. These cases (48 cancers) were randomly allocated for blinded review of (1) DM workup and (2) DBT, both in conjunction with previous DM from the screening examination. Fifteen radiologists of varying experience levels in the Australia BreastScreen Program were included in this study, wherein each radiologist read 48 cases (16 cancers) in 3 non-overlapping blocks. Diagnostic accuracy was measured by means of sensitivity, specificity, and positive (PPV) and negative predictive values (NPV). The receiver-operating characteristic area under the curve (AUC) was calculated to determine radiologists' performances. RESULTS: Use of DBT (AUC = 0.927) led to improved performance of the radiologists (z = 2.62, p = 0.008) compared with mammography workup (AUC = 0.872). Similarly, the sensitivity, specificity, PPV, and NPV of DBT (0.93, 0.75, 0.64, 0.96) were higher than those of the workup (0.90, 0.56, 0.49, 0.92). Most radiologists (80%) performed better with DBT than standard workup. Cancerous lesions on DBT appeared more severe (U = 33,172, p = 0.02) and conspicuous (U = 24,207, p = 0.02). There was a significant reduction in the need for additional views (χ2 = 17.63, p < 0.001) and recommendations for ultrasound (χ2 = 8.56, p = 0.003) with DBT. CONCLUSIONS: DBT has the potential to increase diagnostic accuracy and simplify the assessment process in the breast cancer assessment clinic. KEY POINTS: • Use of DBT in the assessment clinic results in increased diagnostic accuracy. • Use of DBT in the assessment clinic improves performance of radiologists and also increases the confidence in their decisions. • DBT may reduce the need for additional views, ultrasound imaging, and biopsy.

Sentinel lymph node biopsy for head and neck mucosal cancers - an update on the current evidence.

Regional metastases are a prominent feature of mucosal-associated head and neck squamous cell carcinomas and are an important prognostic factor. Sentinel lymph node biopsy (SLNB) is one modality that has potential to add to the accuracy of neck staging, although it is currently not used as widely in the head and neck as it is in other areas such as breast cancer. We review the efficacy of SLNB in head and neck mucosal squamous cell carcinomas and provide an overview of current practice and include details of technical advances.

Digital tomosynthesis: a new future for breast imaging?

The aim of this article is to review the major limitations in current mammography and to describe how these may be addressed by digital breast tomosynthesis (DBT). DBT is a novel imaging technology in which an x-ray fan beam sweeps in an arc across the breast, producing tomographic images and enabling the production of volumetric, three-dimensional (3D) data. It can reduce tissue overlap encountered in conventional two-dimensional (2D) mammography, and thus has the potential to improve detection of breast cancer, reduce the suspicious presentations of normal tissues, and facilitate accurate differentiation of lesion types. This paper reviews the latest studies of this new technology. Issues including diagnostic efficacy, reading time, radiation dose, and level of compression; cost and new innovations are considered.

Online rapid sampling microdialysis (rsMD) using enzyme-based electroanalysis for dynamic detection of ischaemia during free flap reconstructive surgery.

We describe an enzyme-based electroanalysis system for real-time analysis of a clinical microdialysis sampling stream during surgery. Free flap tissue transfer is used widely in reconstructive surgery after resection of tumours or in other situations such as following major trauma. However, there is a risk of flap failure, due to thrombosis in the flap pedicle, leading to tissue ischaemia. Conventional clinical assessment is particularly difficult in such 'buried' flaps where access to the tissue is limited. Rapid sampling microdialysis (rsMD) is an enzyme-based electrochemical detection method, which is particularly suited to monitoring metabolism. This online flow injection system analyses a dialysate flow stream from an implanted microdialysis probe every 30 s for levels of glucose and lactate. Here, we report its first use in the monitoring of free flap reconstructive surgery, from flap detachment to re-vascularisation and overnight in the intensive care unit. The on-set of ischaemia by both arterial clamping and failure of venous drainage was seen as an increase in lactate and decrease in glucose levels. Glucose levels returned to normal within 10 min of successful arterial anastomosis, whilst lactate took longer to clear. The use of the lactate/glucose ratio provides a clear predictor of ischaemia on-set and subsequent recovery, as it is insensitive to changes in blood flow such as those caused by topical vasodilators, like papaverine. The use of storage tubing to preserve the time course of dialysate, when technical difficulties arise, until offline analysis can occur, is also shown. The potential use of rsMD in free flap surgery and tissue monitoring is highly promising.

Litigation in National Health Service oral and maxillofacial surgery: review of the last 15 years.

Litigation claims are increasing in medicine but we know of little detailed analysis of those published concerning oral and maxillofacial surgery (OMFS) despite information being freely available from the NHS Litigation Authority (NHSLA) under the Freedom of Information Act. We obtained information from the NHSLA on clinical and non-clinical negligence claims in OMFS from April 1995 to August 2010, and analysed the data with outcomes and a further breakdown of subspecialty. During the period 318 claims relating to OMFS were registered. As expected, because of the high volume of patients treated, the highest number of claims related to dentoalveolar surgery and minor oral surgery. The total amount paid out was in excess of £5 million, and the highest claim (more than £300,000) during the period was for misdiagnosis of an oral cancer. Litigation in OMFS is increasing, as is the number of cases that necessitate compensation by the NHSLA. We discuss the trends and implications.

Peer Assessment Rating (PAR) index outcomes for orthodontic and orthognathic surgery patients.

The Peer Assessment Rating (PAR) index is commonly used to evaluate occlusal outcomes after orthodontic treatment. We compared the PAR outcomes of 40 consecutively treated orthodontic patients and 40 orthognathic patients to evaluate the standard of care given. A patient-centred questionnaire was used to examine patients' perceptions of the benefits of orthognathic treatment. PAR scores of orthodontic and orthognathic patients improved by a mean of 77% and 74%, respectively, after treatment indicating that excellent to good occlusal results were achieved for both groups. A high quality occlusal outcome is important for all patients as good intercuspation at the end of treatment is thought to improve stability. Most orthognathic patients reported improvements in their dental and facial appearance and thought that the treatment had been beneficial.

Rheumatoid arthritis: a novel radiographic projection for hand assessment.

Rheumatoid arthritis (RA) is the most common form of inflammatory disease, affecting 1-2% of the population. Posteroanterior (PA) and Brewerton projections are well established in radiographic practice for scoring and monitoring RA, but there is little evidence to demonstrate the diagnostic efficacy of these techniques. This work, by varying the positioning of a cadaveric hand, investigates whether an alternative radiographic projection could yield greater diagnostic information than the traditional techniques. Phase I of the study evaluated moving the hand 15 degrees from the anteroposterior position and then in 5 degrees increments in four directions: medial rotation, lateral rotation, flexion of the wrist and extension of the wrist. Phase II of the study took the optimum projections from Phase I and further manipulated these positions in a direction at right angles to the original position. Images were scored based on joint space visualisation in 29 joints. Results demonstrated that significantly higher diagnostic efficacy was evident with 15 degrees lateral rotation of the hand or 15 degrees flexion at the wrist compared to the Brewerton projection. Either projection is recommended, but on the basis of patient comfort, the latter of these novel positions, now known as the UCD projection, was chosen as the optimum procedure to replace the Brewerton projection. The value of using cadavers for the establishment of optimum radiographic procedures is highlighted.

Experiences of technology integration in home care nursing.

The infusion of health care technologies into the home leads to substantial changes in the nature of work for home care nurses and their patients. Nurses and nursing practice must change to capitalize on these innovations. As part of a randomized field experiment evaluating web-based support for home care of patients with chronic heart disease, we engaged nine nurses in a dialogue about their experience integrating this modification of care delivery into their practice. They shared their perceptions of the work they needed to do and their perceptions and expectations for patients and themselves in using technologies to promote and manage self-care. We document three overarching themes that identify preexisting factors that influenced integration or represent the consequences of technology integration into home care: doing tasks differently, making accommodations in the home for devices and computers, and being mindful of existing expectations and skills of both nurses and patients.

Assessment of monitor conditions for the display of radiological diagnostic images and ambient lighting.

Diagnostic efficacy is related to viewing conditions. An increasing number of radiology departments are using workstations for reporting and it was the aim of this study to assess monitor performance and ambient lighting in areas allocated to soft-copy reporting and review. The study was performed in 4 Dublin hospitals and 20 monitors were examined. Using a Society of Motion Pictures and Television Engineers' (SMPTE) test pattern, maximum luminance, spatial uniformity of luminance, temporal luminance stability, brightness and contrast resolution (gamma), geometry and ambient lighting was assessed. The results demonstrated that although temporal luminance stability and spatial uniformity appeared to be at acceptable levels, maximum luminance and gamma value variations were noted, with maximum luminance and geometry values often not complying with published guidelines. Cleaning the monitor face had no impact. 90% of viewing areas had acceptable ambient lighting levels. The data presented demonstrate that monitors examined were not operating at optimal levels for all performance parameters and inclusion of regular assessments of monitors should be part of an imaging department's ongoing quality assurance programme.

High resolution computed tomography and magnetic resonance imaging in the pre-operative assessment of cochlear implant patients.

Optimal imaging protocols for cochlear implantation have yet to be determined. Pre-operative computed tomography (CT) and magnetic resonance image (MRI) scans are used to assess cochlear anatomy and patency, to delineate surgical access, and to aid in choice of side for implantation. However, opinion still differs as to which modality provides more information in pre-operative assessment, or if, indeed, a combination of the two is superior. The first 88 patients on the Irish National Cochlear Implant Programme (NCIP) were retrospectively studied to determine the accuracy of pre-operative CT and MRI in predicting abnormalities at the time of surgery. Correlation with surgical findings was determined in three separate groups of patients (those who had CT only, those who had MRI only, and those who had both CT and MRI performed). Of the 24 patients that had both CT and MRI performed, both modalities had a 79 per cent correlation with surgical findings. CT and MRI reports concurred in 75 per cent of cases. Specificity and negative predictive value were high (86 per cent and 90 per cent, respectively). CT alone (47 cases) correlated with surgery in 39 cases (83 per cent); MRI alone (17 cases) correlated in 15 cases (88 per cent). The findings of this study suggest that CT and MRI are effective at predicting normal inner ear anatomy, and thus at predicting the patient and the cochlea most suitable for implantation. Both modalities are useful in determining the side of implantation, thus avoiding potential surgical difficulties in cases of unilateral abnormalities. There was no significant difference between the ability of MRI and CT to detect abnormalities at the time of surgery. In this series the combination of CT and MRI has not been shown to be superior to either modality used alone, although anecdotal evidence to the contrary was noted.

An assessment of the usefulness of screen-film speed classifications.

Speed classifications of screen-film combinations are frequently quoted in the day-to-day functioning of X-ray departments. These values are utilised for a variety of functions by X-ray personnel. This study aimed to compare a range of commonly used screen-film combinations in order to establish the level of agreement between stated speed classifications and actual speed of systems. Relationships between system speed class and image quality were also investigated. Six commonly used screen-film systems were studied; three had a speed classification of 200 while the remaining systems had a classification of 400. Characteristic curves for each system were produced, from which relative speeds were calculated at four beam energies. Psychophysical tools and visual grading analyses were used to assess image quality. The sensitometric results demonstrated that at all energies the speed class quoted did not predict the actual relative speeds of the film-screen systems. The image quality study demonstrated disagreement with conventional assumptions regarding speed classifications with mean values for 400 speed systems being higher or at least equal to the 200-system scores. There is no evidence from this study to support the ongoing use of current screen-film classifications. Personnel within all X-ray departments should carry out rigorous speed measurements and image quality assessments of all systems within their department before nominal classifications are used.

The role of computerized tomography in the preoperative assessment of chronic suppurative otitis media.

Twenty patients awaiting mastoid surgery for chronic suppurative otitis media underwent preoperative high resolution computerized tomography (CT) of the temporal bones. The CT scans were compared with the intraoperative findings. CT was helpful in determining the anatomy of the middle ear and mastoid, and accurately predicted the extent of the disease process in the sinus tympani and facial recess. However, it was unable to distinguish between cholesteatoma, mucosal disease and fluid, and it contributed little to the surgical management of the patients. This suggests that routine preoperative CT scanning of patients before uncomplicated virgin mastoid surgery is of questionable value.

Consumer informatics supporting patients as co-producers of quality.

The track entitled "Consumer Informatics Supporting Patients as Co-Producers of Quality" at the AMIA Spring 2000 Congress was devoted to examining the new field of consumer health informatics. This area is developing rapidly, as worldwide changes are occurring in the organization and delivery of health care and in the traditional roles of patient and provider. This paper describes the key themes of the track; implications of the growing area of consumer health informatics; and recommendations for informatics research, design, and policy. Key themes that emerged from the panels and discussions involved changes in roles of consumers and providers; supporting a patient-provider-information technology partnership; virtual, not physical, structure for health care and health care information delivery; and health care as an integrated part of one's life. Panelists and participants at the Congress developed recommendations for informatics research, design, and policy, with an overarching focus on how to support the patient-provider-information technology partnership to provide more patient-centered health care. They recommended that AMIA take an active leadership role in consumer health informatics. Specific recommendations were made concerning research, new patient record systems, provider support, information access and evaluation, and policy and regulation.