[The situation of education in ENT-residency-training in Germany]. / Die Weiterbildungssituation in der HNO-Heilkunde in Deutschland.

BACKGROUND: As a starting point for developing concrete suggestions for optimizing specialty training in German ENT departments, the present study analysed the current status of residency training in order to identify weaknesses. METHODS: Residents at German ENT departments were invited to participate in an online survey. The questionnaire comprised 78 individual questions. RESULTS: The questionnaire was answered by 223 ENT residents. Educational deficits such as a lack of regular feedback from supervisors, only moderately rated mediation of specialist competencies, capriciousness of the trainers in charge regarding the organisation of training, and time and personnel shortages were identified. Some of the mandatory recommendations of the specialty training regulations, including determination of concrete training goals during regular meetings or the use of a logbook, have only been implemented in limited cases. Demands for development of more external training opportunities (job shadowing/rotation) and an external objective review of the residency training (e.g., by a representative of the German Society of Otorhinolaryngology, Head and Neck Surgery, DGHNOKHC) in the sense of quality assurance are discussed. CONCLUSION: Implementation of structured and standardized ENT residency training in Germany, for which DGHNOKHC reviewal is also possible, can generate a basis for more effective compulsory residency training.

[From reconstruction to function : Hands-on training in tympanoplasty using real-time feedback]. / Von der Rekonstruktion zur Funktion : Tympanoplastik-Training mit Real-Time-Feedback.

BACKGROUND: Surgery of the middle ear requires a very high level of fine motor skills. Due to the increased potential for complications in middle ear operations, it is appropriate to acquire these skills beforehand by operating on a model. OBJECTIVE: How satisfactory is the training on suitable models? Are the skills acquired from working on a model transferable to intraoperative situations? Will the type of model and its use for training influence ear surgery in the future? MATERIAL AND METHODS: Available publications and own experiences with the Dresden tympanoplasty model (DTM) are analyzed and discussed. RESULTS: Although middle ear surgery makes very high demands on the surgeon and there is a significant risk for severe complications to the ear as a sense organ, there are currently very few options to train surgeons in advance. The DTM is a validated training model, which is capable of closing this gap. Due to the possibility of using a real-time feedback variation of the model, the understanding for reconstruction quality and intraoperative acoustic stress can be improved. The translation of the real-time feedback idea into actual middle ear surgery can improve reconstruction quality in the future. CONCLUSION: Training on suitable models is indispensable, especially when training as a surgeon to carry out middle ear operations. Adding another sense perception to the internal and external quality assessment of tympanoplasty by inclusion of the real-time feedback option, can optimize learning and operating processes.

[Learning curve of the ENT mirror examination : Goal-oriented curriculum planning for psychomotor learning]. / Lernkurve der HNO-Spiegeluntersuchung : Zielgerichtete Lehrveranstaltungsplanung zu einer psychomotorischen Fertigkeit.

BACKGROUND: Learning complex psychomotor sequences requires a high number of training sessions to achieve precise execution. In the current student curriculum there are only few study sessions available to achieve this level of competence. OBJECTIVE: The objective of the current study was to record the learning curve of psychomotor proficiency using the example of the ENT mirror examination. Particular focus was on the number of practice sessions needed to achieve safe execution of the examination and the learning success as assessed in partial investigations. MATERIALS AND METHODS: During a 5­day period of their ENT block internship, students were taught and practiced the correct ENT mirror examination. At the end of each internship day, the learning progress of a total of 48 students was statistically evaluated by a checklist-based assessment. RESULTS: In the full study and in the partial studies, a significant increase in points was shown over the days, which proved a growing learning curve of the students. The students required at least five training sessions (each 45 min) for safe execution (Bloom taxonomy level 3) and six training sessions for routine execution (Bloom taxonomy level 4; Nationaler kompetenzorientierter Lernzielkatalog Medizin, NKLM, level 3a). CONCLUSION: Looking at the ENT mirror examination, an improvement in psychomotor skills was shown with an increasing number of practice sessions. This study is therefore representative as an example of resource-optimized curriculum planning based on the previously defined level of competence that students should have attained by the end of a course.

Defibrillator charging before rhythm analysis causes peri-shock pauses exceeding guideline recommended maximum 5 s : A randomized simulation trial.

INTRODUCTION: Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged. METHODS: This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand. RESULTS: A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07). CONCLUSION: Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups.

Tube tip and cuff position using different strategies for placement of currently available paediatric tracheal tubes.

BACKGROUND: Tracheal tube tip and cuff positions of different cuffed paediatric tracheal tube brands in the trachea can vary with design. METHODS: Data from three clinical studies with measured tracheal lengths were pooled in a database including 422 children aged from birth to 16 yr. Dimensional data of seven cuffed paediatric tracheal tube brands (ID 3.0-7.0 mm) were recorded. Positions of tracheal tube tip and upper cuff border were calculated for each of the 422 tracheas using depth mark based tracheal tube placement, placement of the tracheal tube tip at a calculated safety distance above the carina, and mid-tracheal tube placement. Percentage of accidental bronchial intubations and tracheal tube cuff positions in the subglottic or supraglottic region were calculated. RESULTS: Depth mark based tracheal tube placement resulted in accidental bronchial intubation of up to 18% of cases and tracheal tube cuffs being placed in the subglottic region in up to 91%. Tracheal tube tip placement at a calculated safety distance resulted in up to 54% of tube cuffs placed too high. Mid-tracheal tube placement led to 100% subglottic or supraglottic tracheal tube cuff positions. CONCLUSIONS: All studied cuffed paediatric tracheal tubes have major design flaws potentially leading to airway complications. Tracheal tube manufacturers are urgently asked to improve the design of cuffed paediatric tracheal tubes. Alternative strategies for tracheal tube placement can allow safe tracheal tube placement of uncuffed but not of cuffed tracheal tubes.

Patency of paediatric endotracheal tubes for airway instrumentation.

BACKGROUND: Airway exchange catheters (AEC) and fiberoptic bronchoscopes (FOB) for tracheal intubation are selected so that there is only a minimal gap between their outer and inner diameter of endotracheal tube (ETT) to minimize the risk of impingement during airway instrumentation. This study aimed to test the ease of passage of FOBs and AECs through paediatric ETT of different sizes and from different manufacturers when using current recommendations for dimensional equipment compatibility taken from text books and manufacturers information. METHODS: Twelve different brands of cuffed and uncuffed ETT sized ID 2.5 to 5.0 mm were evaluated in an in vitro set-up. Ease of device passage as well as the locations of an impaired passage within the ETT were assessed. Redundant samples were used for same sized ETT and all measurements were triple-checked in randomized order. RESULTS: In total, 51 paired samples of uncuffed as well as cuffed paediatric ETT were tested. There were substantial differences in the ease of ETT passage concordantly for FOBs and AECs among different manufacturers, but also among the product lines from the same manufacturer for a given ID size. Restriction to passage most frequently was found near the endotracheal tube tip or as a gradually increasing resistance along the ETT shaft. CONCLUSIONS: Current recommendations for dimensional equipment compatibility AECs and FOBs with ETTs do not appear to be completely accurate for all ETT brands available. We recommend that specific equipment combinations always must be tested carefully together before attempting to use them in a patient.

[Acute Kidney Failure Due to Urachal Cyst?] / Akutes Nierenversagen bei Urachuszyste?

A 34-year-old para V woman was referred to our centre at 35+1 weeks of gestation for an assumed fetal malformation with prenatal renal impairment and anhydramnios. Prenatal ultrasound demonstrated unilateral renal agenesis; the bladder was not detectable. The baby was born by caesarian section at 36+2 weeks of gestation because of placental insufficiency. Postnatal adaptation was uneventful, but the newborn presented external stigmas of trisomy 21 and progressive renal impairment with anuria. Nevertheless, the postnatal ultrasound showed two enlarged kidneys in loco typico with impaired perfusion but without signs of malformations. In the lower abdomen, a rosette-shaped structure of unknown origin was noted. Its origin could not be cleared by imaging including voiding cystourethrography and colon contrast radiography. Explorative laparotomy identified the structure as a persistent urachal cyst with secondary obstruction of the upper urinary tract. After removal of the urachus with reconstruction of the bladder dome, renal function recovered completely while urine was drained continuously via suprapubic catheter. A voiding cystourethrogram 3 weeks later showed a posterior urethral valve as an additional unexpected diagnosis. The valve was slit at the age of 6 months without complications, the renal function remained stable in the further course. In retrospect, the main cause for the renal failure remains unclear. It appears to be the obstruction due to the space-consuming character of the urachal cyst, especially because the megacystis typically associated with urethral valve was not viewable. Alternatively, the additional proximal stenosis may have only masked the typical findings of PUV.

Nasotracheal intubation depth in paediatric patients.

BACKGROUND: The aim of this study was to compare intubation depth using the Microcuff paediatric endotracheal tube (PET) placed with the intubation depth mark between the vocal cords with that of different published formulae/recommendations for nasotracheal intubation depth in children. METHODS: Children aged from birth to 10 yr undergoing elective surgery with nasotracheal intubation were included. Tracheal tubes were adjusted according to the intubation depth mark between the vocal cords using direct laryngoscopy. Nasal intubation depth was recorded and the distance 'tube tip to carina' was measured endoscopically. Based on the recorded nasal intubation depth and measured distance 'tube tip to carina', the position of tube tip and cuff was calculated according to six published formulae/recommendations. RESULTS: Seventy-six children were studied. For the Microcuff PET, the median tube tip advancement within the trachea was 52.9% (41.1-73.8%) of tracheal length. The shortest distance from the 'tube tip to carina' was 15 mm for a 3.5 mm internal diameter tube. If the six published formulae/recommendations had been used, this would have resulted in endobronchial tube placement in up to 9.1% of cases, and the tube tip would have been placed above the glottis in up to 2.6% of cases. The upper border of the cuff would have been placed in the subglottic area in up to 42.1% of cases and in a supraglottic position in up to 63.2% of cases. CONCLUSIONS: This study indicates that nasal intubation with the intubation depth mark placed between the vocal cords was superior to formula-based nasotracheal tube positioning. The latter would result in a high rate of endobronchial intubations, excessively high cuff positions and even tracheal extubations.

[Intubation with a tube exchanger on an intubation trainer. Influence of tube tip position on successful intubation]. / Intubation über den Tubuswechsler an einem Intubationstrainer. Einfluss der Tubusspitzenposition auf den Intubationserfolg.

BACKGROUND: Securing the airway using a tube exchanger catheter is an important and useful technique in anesthesia. Its success is mainly hampered by tube tip impingement of laryngeal structures. Advancing the tracheal tube along its normal curvature via a tube exchanger catheter has a high risk of tube tip impingement mainly of right laryngeal structures. The authors achieved successful clinical experience by rotating the tracheal tube 90° anticlockwise (ventral tube tip position) before railroading the tube via a tube exchanger catheter or a fiber optic bronchoscope through the larynx. AIM: The aim of the study was to investigate the influence of the tracheal tube tip position while intubating an airway trainer over a tube exchange catheter. MATERIAL AND METHODS: Volunteer anesthetists with varying years of professional experience were asked to intubate an intubation mannequin (Laerdal Airway Management Trainer) using the orotracheal route with an established tube exchange catheter (Cook Airway Exchange Catheter, 11F). Two different brands of tracheal tubes (Rüsch and Covidien, ID 7.0 mm) were used in a randomized order, each with the tracheal tube tip at first positioned right (90°), then ventrally (0°), left (270°) and finally dorsally (180°), resulting in eight intubation attempts for each participant. To ensure the correct tube tip position the tube was withdrawn before every intubation attempt until the tube tip position was visualized. The oropharnyx, larynx, trachea and tube were sufficiently lubricated with silicon spray (Rüsch Silikospray). The tube and airway exchange catheter size selection were made according to the clinical trial of Loudermilk et al. Successful endotracheal intubation without resistance was recorded for each tube tip position and tracheal tube brand. RESULTS: In total 20 anesthetists (13 consultants and 7 residents) with a median of 9.5 years (range 3-37 years) of professional experience participated in the study. Overall 160 intubation attempts were performed, 2 participants showed no successful intubation attempts at all and 38 out of 160 intubation attempts (23.8 %) were successful. Intubation success with the tracheal tube tip placed ventrally (0°) was 60 % followed by the left (270°) and right (90°) tracheal tube tip positions with 27.5 % and 7.5 % intubation success, respectively. With the tube tip placed dorsally (180°) none of the 40 intubation attempts were successful. Intubation attempts with the Rüsch tube were more successful (28.8 %) than those with the Covidien tube (18.8 %). Placing the tracheal tube tip ventrally, the Rüsch tube was twice as successful as the Covidien tube with 16 (80 %) versus 8 attempts (40 %, p = 0.011). There was no correlation between professional experience and intubation success (p = 0.362). CONCLUSION: Tube insertion via an airway exchange catheter or a fiberoptic bronchoscope is a basic technique in anesthesia. Knowledge about the difficulties and their prevention are essential for every anesthetist. The gap between the airway exchange catheter, the fiber bronchoscope and the tube diameters is one of the major reasons for tube tip impingement. This investigation showed that intubation success via a tube exchange catheter, as investigated in an intubation mannequin, is considerably influenced by the tracheal tube tip position. A 90° anticlockwise rotation, placing the tracheal tube tip ventrally, considerably increased intubation success. This is of particular importance if an anesthesia department has no appropriately sized tube exchange catheters or fiber bronchoscope for every age group of patients.

[Peer teaching and peer assessment are appropriate tools in medical education in otorhinolaryngology]. / Peer Teaching und Peer Assessment sind effektive Lehrinstrumente in der HNO-Heilkunde.

BACKGROUND: The use of student tutors (peers) is an accepted method in medical education. In 2011, final year students of the otorhinolaryngology (ORL) department of the University Hospital in Dresden were appointed as peers for the clinical ORL examination. They assisted in the instruction of the clinical ORL examination (peer teaching, PT) and served as examiners (peer assessment, PA) in the final objective structured clinical examination (OSCE). The effect on the quality of education and examination was examined. MATERIAL AND METHODS: 248 medical students (5(th) year) were divided in 2 groups. They were trained and finally examined in the standardized clinical ORL examination by peers and/or physicians. Group I (n=118) was exclusively trained and examined by physicians and group II (n=130) by peers and physicians. The results of the OSCE were stratified for the 2 groups and in group II for the subgroups according to the instructors' and examiners' qualification (peer or physician). The students evaluated the internship and the instructors' and examiners' quality with a validated questionnaire. RESULTS: In the OSCE, group I scored in the mean 59.9±4.9 points (max. 65). In group II the mean score was 58.3±4.3 points examined by the peers and 59.5±4.8 points for same performance assessed by the physicians. There were no statistical significant differences in the examination results when stratified for the instructors' and examiners' qualification. The evaluation results were consistently positive and identical when compared to the previous year without use of PT and PA and between the 2 groups and subgroups. CONCLUSIONS: When using a standardized clinical examination routine peers can be used for PT and PA to appropriate tools in student's medical education without any decrease in the teaching and examination quality.

Growing experience with mTOR inhibitors in pediatric solid organ transplantation.

Controlled trials of mTOR inhibitors in children following solid organ transplantation are scarce, although evidence from prospective single-arm studies is growing. Everolimus with reduced CNI therapy has been shown to be efficacious and safe in de novo pediatric kidney transplant patients in prospective trials. Prospective and retrospective data in children converted from CNI therapy to mTOR inhibition following kidney, liver, or heart transplantation suggest preservation of immunosuppressive efficacy. Good renal function has been maintained when mTOR inhibitors are used de novo in children following kidney transplantation or after conversion to mTOR inhibition with CNI minimization. mTOR inhibition with reduced CNI exposure is associated with a low risk for developing infection in children. Growth and development do not appear to be impaired during low-dose mTOR inhibition, but more studies are required. No firm conclusions can be drawn as to whether mTOR inhibitors should be discontinued in children requiring surgical intervention or whether mTOR inhibition delays progression of hepatic fibrosis after pediatric liver transplantation. In conclusion, current evidence suggests that use of mTOR inhibitors in children undergoing solid organ transplantation is efficacious and safe, but a number of issues remain unresolved and further studies are required.

Adjusting the RAPID score with 2 additional variables significantly increases its predictive value in patients with empyema.

Pleural empyema is a serious condition leading to a significant burden on health care systems due to protracted hospitalisations. Treatment ranges from non-surgical interventions such as antibiotic therapy and chest tube placement to thoracoscopic or open surgery. Various risk factors which impact outcomes have been investigated. The RAPID (renal, age, purulence, infection source, and dietary factors) score is a clinical risk score which identifies patients at risk of death and may be used to formulate individual treatment strategies accordingly. All patients undergoing surgical interventions for empyema at a major tertiary medical centre in Germany from 2017 to 2020 were analysed. The aim was to identify perioperative risk factors which significantly impact treatment outcomes but are currently not included in the RAPID score. 245 patients with pleural empyema surgically treated at the Department of General, Visceral and Thoracic Surgery at the University Medical Centre, Hamburg, Germany (admitted from January 2017 to April 2020) were retrospectively analysed. All patients which received either minimally invasive or open thoracic surgery were included. Epidemiological as well as perioperative data was analysed to identify risk factors which impact long-term overall outcomes. 90-day mortality rate was the primary endpoint. The mean age was 59.4 years with a bimodal distribution. There was a male predominance across the cohort (71.4% compared to 28.6%), with no significant differences across ages below or above 60 years. 53 (21.6%) patients died within the first 90 days. Diabetes type 1 and 2, renal replacement therapy, immunosuppression, postoperative bleeding, intraoperative transfusion as well as microbiologically confirmed bacterial invasion of the pleura all led to higher mortality rates. Higher RAPID scores accurately predicted higher 90-day mortality rates. Modifying the RAPID score by adding the comorbidities diabetes and renal replacement therapy significantly increased the predictive value of the score. We demonstrated various perioperative and patient related risk-factors not included in the RAPID score which negatively impact postoperative outcome in patients receiving surgical treatment for pleural empyema. These should be taken into consideration when deciding on the best course of treatment. If confirmed in a prospective study including non-surgical patients with a significantly larger cohort, it may be worth considering expanding the RAPID score to include these.

Interactions between protein coated particles and polymer surfaces studied with the rotating particles probe.

Nonspecific interactions between proteins and polymer surfaces have to be minimized in order to control the performance of biosensors based on immunoassays with particle labels. In this paper we investigate these nonspecific interactions by analyzing the response of protein coated magnetic particles to a rotating magnetic field while the particles are in nanometer vicinity to a polymer surface. We use the fraction of nonrotating (bound) particles as a probe for the interaction between the particles and the surface. As a model system, we study the interaction of myoglobin coated particles with oxidized polystyrene surfaces. We measure the interaction as a function of the ionic strength of the solution, varying the oxidation time of the polystyrene and the pH of the solution. To describe the data we propose a model in which particles bind to the polymer by crossing an energy barrier. The height of this barrier depends on the ionic strength of the solution and two interaction parameters. The fraction of nonrotating particles as a function of ionic strength shows a characteristic shape that can be explained with a normal distribution of energy barrier heights. This method to determine interaction parameters paves the way for further studies to quantify the roles of protein coated particles and polymers in their mutual nonspecific interactions in different matrixes.

Spin-spin interactions in organic magnetoresistance probed by angle-dependent measurements.

The dependence of organic magnetoresistance (OMAR) on the orientation of the magnetic field has been investigated. In contrast with previous claims, a finite and systematic change in magnitude is observed when the orientation of the field is changed with respect to the sample. It is demonstrated that, to explain these effects, spin-spin interactions have to be included in the models previously suggested for OMAR. Dipole coupling and exchange coupling are introduced in combination with either an anisotropy of the orientation of the spin pairs or an anisotropy in the hyperfine fields.

[Operationalization of the clinical head and neck examination]. / Die Operationalisierung der HNO-Spiegeluntersuchung.

Standardized procedures support learning of complex psychomotoric activities. We standardized the clinical otolaryngology examination to provide an objective basis for its operationalization. The Impact of the standardization on the objective measureable learning success and the student's evaluation were determined.During their 1-week ENT internship 166 medical students learned the standardized clinical otolaryngology examination. At the end of this week they absolved an objective structured clinical examination (OSCE). The students evaluated both, the teaching (standardization) and examination method (OSCE) with 2 questionnaires.All students passed the exam with mean score of 60.3±3.5 (max. 65) points. By using the OSCE checklist 2 independent examiners appraised nearly identical examination performances. In both evaluations the students rated the teaching and examination design positive. All students greatly appreciated the standardized clinical examinations and considered it as are very important for learning practical skills.The standardization of clinical otolaryngology examination permits objective and reliable tests for learning progress and success. Furthermore transparency, process reliability and test quality are considerably improved. The student's evaluation clearly reflects the mentioned advantages.

[Evaluation of the Dresden Tympanoplasty Model (DTM)]. / Evaluation des Dresdner Tympanoplastik Modells (DTM).

The training of microsurgical motor skills is essentiell for surgical education if the interests of the patient are to be safeguarded. In otosurgery the complex anatomy of the temporal bone and variations necessitate a special training before performing surgery on a patient. We therefore developed and evaluated a simplified middle ear model for acquiring first microsurgical skills in tympanoplasty.The simplified tympanoplasty model consists of the outer ear canal and a tympanic cavity. A stapes model is placed in projection of the upper posterior tympanic membrane quadrant at the medial wall of the simulated tympanic cavity. To imitate the annular ligament flexibility the stapes is fixed on a soft plastic pad. 41 subjects evaluated the model´s anatomical analogy, the comparability to the real surgical situation and the general model properties the using a special questionnaire.The tympanoplasty model was very well evaluated by all participants. It is a reasonably priced model and a useful tool in microsurgical skills training. Thereby, it closes the gap between theoretical training and real operation conditions.

[Lambliasis as differential diagnosis of MARSH type 3b]. / Lamblieninfektion als Differenzialdiagnose der Zöliakie in der Duodenalbiopsie.

Giardia lamblia is the most common human parasite with a worldwide distribution and fecal-oral way of transmission. Diagnostic procedures include stool examination and gastroduodenoscopy with biopsy or secret aspiration. In most cases histology reveals a dense accumulation of the parasites on the surface of the duodenal mucosa with no or only slight inflammation. In rare cases, a dense inflammatory infiltrate with severe mucosal atrophy and increased count of intraepithelial lymphocytes may be seen. If in such cases the amount of parasites is low, the histological picture may mimic celiac disease. The two presented cases demonstrate the close morphological relationship and show the importance of considering giardiasis in the differential diagnosis in patients with suspected celiac disease.

[Medical education in otorhinolaryngology in Germany. Implementation of the new licensing regulations for physicians]. / Lehre der HNO-Heilkunde in Deutschland. Umsetzung der neuen ärztlichen Approbationsordnung.

BACKGROUND: In 2003 new regulations for the licensing of German physicians came into effect. The aim of this study was to survey the present status of realization in German otorhinolaryngology (ORL) university departments. METHODS: A questionnaire containing 31 items was sent to all German ORL university departments. RESULTS: A total of 31 (86%) ORL departments responded to the questionnaire. Most faculties reacted correctly in the practical realization of the new regulation demands. Regarding the quality of written and practical examinations, some changes have to be considered in order to maintain high quality standards. CONCLUSION: The demands of the new licensing regulations have not yet been fully implemented. Therefore, medical education must gain importance in the daily clinical routine. Establishment of nationwide learning objectives and resources pooling for written examinations would be helpful.