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Tryptase is the most abundant endopeptidase released by mast cells degranulation, involved in many pro and anti-inflammatory processes. Normal serum tryptase range is 0-11.4 μg/L. Tryptase is a useful diagnostic tool for anaphylaxis, systemic mastocytosis (SM) and mast cell activation syndrome (MCAS), where specific threshold values must be used. SM diagnosis criteria include evidence of dense mast cell infiltrate either in the bone marrow or the affected organ (such as skin), presence of KIT D816V mutation and elevated serum tryptase level (>20 μg/L). In SM, tryptase level is correlated with the burden of mast cells in bone marrow. MCAS should be considered in case of severe and recurrent typical clinical signs of systemic mast cell activation involving at least two organs, associated with an increase in serum tryptase level of 20% + 2 μg/L from the individual's baseline. Anaphylaxis is the most severe among hypersensitivity reactions. A clonal mast cell disorder is a central question in anaphylaxis and appropriate explorations should be conducted in these patients. Triggers for anaphylactic reactions vary significantly in the general population and in patients with MS or MCAS. Finally, physicians must be aware of the many pathological and physiological situations that affect tryptase levels., (Copyright © 2020. Published by Elsevier Masson SAS.)

To provide optimal patient care, rheumatologists must be equipped and motivated to critically appraise the literature. The conceptual frameworks Retrieval Enhanced Learning, Self-Determination Theory, and Communities of Practice can inform the design of educational approaches to promote critical appraisal in practice. HSS CLASS-Rheum® is a learning tool that can be used to help rheumatologists learn skills for critical appraisal through retrieval practice. Combining retrieval practice with opportunities for connection through Peer Instruction, journal clubs, and other forums can help support engagement and internalization of motivation, promoting persistence with critical appraisal in practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The field of rheumatology has expanded rapidly in recent years, and innovations in immunology, epigenetics, and bone metabolism continue at an astonishing pace. In this fast changing field, optimizing medical education for rheumatologists is vital for maintaining a competent workforce to meet the needs of patients with rheumatic diseases. Several key challenges lie ahead and efforts to optimize medical education for rheumatologists are discussed in this article., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The Hospital Privileges Practice Guideline Writing Group of the Society for Vascular Surgery is making the following five recommendations concerning guidelines for hospital privileges for vascular surgery and endovascular therapy. Advanced endovascular procedures are currently entrenched in the everyday practice of specialized vascular interventionalists, including vascular surgeons, but open vascular surgery remains uniquely essential to the specialty. First, we endorse the Residency Review Committee for Surgery recommendations regarding open and endovascular cases during vascular residency and fellowship training. Second, applicants for new hospital privileges wishing to perform vascular surgery should have completed an Accreditation Council for Graduate Medical Education-accredited vascular surgery residency or fellowship or American Osteopathic Association-accredited training program before 2020 and should obtain American Board of Surgery certification in vascular surgery or American Osteopathic Association certification within 7 years of completion of their training. Third, we recommend that applicants for renewal of hospital privileges in vascular surgery include physicians who are board certified in vascular surgery, general surgery, or cardiothoracic surgery. These physicians with an established practice in vascular surgery should participate in Maintenance of Certification programs as established by the American Board of Surgery and maintain their respective board certification. Fourth, we provide recommendations concerning guidelines for endovascular procedures for vascular surgeons and other vascular interventionalists who are applying for new or renewed hospital privileges. All physicians performing open or endovascular procedures should track outcomes using nationally validated registries, ideally by the Vascular Quality Initiative. Fifth, we endorse the Intersocietal Accreditation Commission recommendations for noninvasive vascular laboratory interpretations and examinations to become a Registered Physician in Vascular Interpretation, which is included in the requirements for board eligibility in vascular surgery, but recommend that only physicians with demonstrated clinical experience in the diagnosis and management of vascular disease be allowed to interpret these studies., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition when molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions., Objective: The purpose of this article was to review the research-based evidence for the effectiveness of self-assessment and to provide suggestions for its use in clinical teaching and practice in EM., Discussion: This article reviews hypothesis-testing research related to self-assessment behaviors and learning. Evidence indicates that self-assessment is inherently flawed when used in isolation. We review a multi-dimensional approach to informed self-assessment that can serve as the basis for life-long learning and development., Conclusions: Advancing EM education will require that high-quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The informed self-assessment framework is a method that is applicable to teaching and practice in EM., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to validate a continuing medical education e-learning tool., Methods: The CME MMC was for all health professionals maternity Burgundy and concerned regional morbidity and mortality conferences. It was divided into steps: a pre-test for an assessment of initial knowledge, an access to the recommendations of each RMM and a post-test to assess the progress of participants. A satisfaction questionnaire was proposed after the test. The primary endpoint was the comparison of the post-test scores than the pre-test., Results: CME MMC was opened 3 months and recorded 156 participants among 598 health professionals in Burgundy, a rate 2.4 times higher than the average participation rate at MMC the past two years. A statistically significant increase was demonstrated individually by comparing the post-test scores than the pre-test (P<0.00001). The increase was significantly higher for midwives and professionals absents at the RMM. Finally, 96.2% of participants have been satisfied by this formation., Conclusion: This prospective multicenter study validates our tool. CME MMC is accessible, without geographic or time restrictions, not expensive, and efficient because it proves that it can update our knowledge in obstetrics and perinatology., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Over the course of a century, American medical specialty boards including the American Board of Ophthalmology (ABO) have developed significant expertise in assessing physician competence on completion of postgraduate training and, more recently, in defining appropriate criteria for continuous learning and quality improvement in practicing physicians. This article explores why maintaining career-long excellence is an evolving challenge, but one that is at the heart of the ABO's mission to protect the public by improving patient care., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: In Advanced Trauma Life Support (ATLS©) courses, multiple choice question (MCQ) tests are used to assess student's post course knowledge. As part of the ninth Edition Revision Process, existing MCQ tests were reviewed and revised by an International MCQ Revision group. The aim of this study was to evaluate the revision procedure and its effects., Methods: Based on psychometric data and evidence based guidelines for adequate MCQ item and test development, a detailed stepwise approach was determined and followed to evaluate the existing MCQs, and to guide test item revision or replacement., Results: The MCQ Revision group composed three new draft test versions comprising of 40 MCQs each. These were beta-tested among ATLS Instructors in various countries involved in ATLS. Psychometric analysis demonstrated that a minority of MCQ items required revision to create three equally balanced tests. After these final adjustments, a new set of three validated MCQ tests was available for use in 9th edition ATLS provider courses. Beta testing was performed using instructors but not students. The failure rate amongst students of ATLS provider courses increased significantly after introduction of the new MCQ tests., Conclusion: ATLS tests were revised and updated using current evidence based guidelines and psychometric analysis. Difficulty of the tests was not initially beta-tested on students. Increasing test item discrimination and quality resulted in lower test scores by students., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The ABR has recently reviewed and revised its policy establishing how ABR diplomates may comply with requirements for Maintenance of Certification Part 4: Practice Quality Improvement (PQI). The changes were deemed necessary by the Board of Trustees to acknowledge and credit the numerous ways in which radiology professionals contribute to improving patient care through existing and evolving activities available to them within the radiology community. In addition to meeting requirements by completing a traditional PQI project, the policy revision now allows diplomates to meet criteria by completing one of a number of activities in an expanded spectrum of PQI options recognized by the ABR. The new policy also acknowledges the maturing state of quality improvement science by permitting PQI projects to use "any standard quality improvement methodology," such as Six Sigma, Lean, the Institute for Healthcare Improvement's Model for Improvement, and others in addition to the previously prescribed three-phase plan-do-study-act format., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

In 2011, the American Board of Medical Specialties approved a pilot project submitted by the American Board of Radiology for a Focused Practice Recognition in Brachytherapy initiative. Developers had anticipated significant interest within the profession and had hoped that the project would stimulate clinical interest, research, and education in the modality. A centerpiece of the project was a National Brachytherapy Registry, which was to serve as a dynamic longitudinal database for participants and the profession. Ultimately, the project did not achieve its anticipated goals and was terminated by the American Board of Radiology in 2015. Development, implementation, problems encountered, and potential implications and solutions are discussed., (Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Introduction: Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios., Materials and Methods: A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics., Results: A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively., Conclusions: A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Burn patients often receive their initial care by non-burn specialist clinicians, with increasingly collaborative burn models of care. The provision of relevant and accessible education for these clinicians is therefore vital for optimal patient care., Design/methods: A two phase design was used. A state-wide survey of multidisciplinary non-burn specialist clinicians throughout Western Australia identified learning needs related to paediatric burn care. A targeted education programme was developed and delivered live via videoconference. Pre-post-test analysis evaluated changes in knowledge as a result of attendance at each education session., Results: Non-burn specialist clinicians identified numerous areas of burn care relevant to their practice. Statistically significant differences between perceived relevance of care and confidence in care provision were reported for aspects of acute burn care. Following attendance at the education sessions, statistically significant increases in knowledge were noted for most areas of acute burn care., Conclusions: Identification of learning needs facilitated the development of a targeted education programme for non-burn specialist clinicians. Increased non-burn specialist clinician knowledge following attendance at most education sessions supports the use of videoconferencing as an acceptable and effective method of delivering burns education in Western Australia., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Emergency medicine has been a stronghold of simulation-based training ever since high-fidelity simulators became available. The preclinical setting differs remarkably from any in-hospital environment in both available technology and resources, and thus stress levels of the health-care professionals involved in patient care – ideal factors for the simulation-based teaching approach. This review reports on the current status of the method for teaching preclinical scenarios from an educational and practical perspective. Particular attention is given to contents, formats, and evaluation of success., (Copyright © 2015. Published by Elsevier Ltd.)

In the Netherlands so-called Diabetes Care Groups organize the primary diabetes care centrally with delegation to different health care providers. A training course for general practitioners who would like to become experts in diabetology in the primary care setting meets the need to guide the quality management processes in these care groups., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Introduction: Standardized courses for the care of the burn patient have historically been developed in High Income Countries (HIC). These courses do not necessarily reflect the challenges and needs of Low Income Countries (LIC) and some components may not be relevant there (i.e. use of ventilators in a country that has no or very limited number of ventilators). We are developing a Burn Management Course for East Africa. This course was created and trialed in a LIC and subsequently a formal manual and course curriculum created. Recently the first iteration of the course was undertaken in a major regional burn centre in East Africa. We present participant feedback on the course content, and potential future directions for course development., Objective: (1) To evaluate the ability of a standardized burn course for LIC to meet the needs of the participants. (2) To explore characteristics of burn care and needs related to delivery of burn care in LIC., Methods: 21 students participated in a multidisciplinary burn management course. They were asked to complete an anonymous questionnaire at the end of the course., Results: There were 11 nurses, 6 doctors, a physiotherapist, occupational therapist, and a dietician. 15 worked in either the adult or pediatric burn units, the other six worked in emergency, ICU or the operating room. The majority of respondents (56%) had less than 3 years of experience working with burn patients. Overall agreement that the course met their objectives was rated as 4.6 out of 5. As well the students agreement that they had a better understanding of burn injury was rated as 4.8/5. 55.6% indicated that scalds were the most commonly seen injury followed by 27.8% responding that flames were the most common. Some responses to the question of top difficulties facing the caregivers were similar to HIC: staffing shortages, bed shortages, and finding useable donor site in large burns. Other responses highlighted the challenges these care givers face: poverty stricken patients, not enough appropriate food available, and deficiencies in infection control practices., Conclusion: It is possible to create a course that translates knowledge from a HIC setting to meet the needs of the end-user in a LIC setting., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Background: The Lifelong Learning and Self-assessment (LLSA) component of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program is a self-assessment exercise for physicians. Beginning in 2011, an optional continuing medical education (CME) activity was added., Objectives: As a part of a CME activity option for the LLSA, a survey was used to determine the relevancy of the LLSA readings and the degree to which medical knowledge garnered by the LLSA activity would modify clinical care., Methods: Survey results from the 2011 LLSA CME activity were reviewed. This survey was composed of seven items, including questions about the relevancy of the readings and the impact on the physician's clinical practice. The questions used a 5-point Likert scale and data underwent descriptive analyses., Results: There were 2841 physicians who took the LLSA test during the study period, of whom 1354 (47.7%) opted to participate in the 2011 LLSA CME activity. All participants completed surveys. The LLSA readings were reported to be relevant to the overall clinical practice of Emergency Medicine (69.6% strongly relevant, 28.1% some relevance, and 2.3% little or no relevance), and provided information that would likely help them change their clinical practices (high likelihood 38.8%, some likelihood 53.0%, little or no change 8.2%)., Conclusions: The LLSA component of the ABEM MOC program is relevant to the clinical practice of Emergency Medicine. Through this program, physicians gain new knowledge about the practice of Emergency Medicine, some of which is reported to change physicians' clinical practices., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Postgraduate clinical training in infectious diseases in Japan is still under-developed and needs further improvement. There are both quantitative and qualitative problems that need to be overcome. The system is unusual and two-layered, precluding young applicants from participating in many fellowship programs. To-date, less than half the programs actually have acting fellows involved in training. The system needs fundamental reform, with a better evaluation system for each program., (Copyright © 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: The "July phenomenon" describes poor patient outcomes in teaching hospitals at the beginning of a new academic year when trainees begin. Whether this phenomenon truly exists is unclear., Objective: The purpose of this study was to identify whether trainee and attending inexperience is associated with cardiac electrophysiologic procedural outcomes including total procedure time, fluoroscopy time, and complications., Methods: We retrospectively reviewed the available electronic records of 488 consecutive patients undergoing initial dual-chamber pacemaker (PM) or cardiac resynchronization therapy (CRT) device implantation performed at University of California, San Francisco from February 2004 through November 2011. We calculated physician's year of experience using the procedure date and the physician's job start date. Patients were stratified into two subgroups based on their device type. Procedural outcomes including procedure length, fluoroscopy time, and complications were retrieved from electronic databases., Results: After multivariate analysis, fellow experience was associated with decreased procedure time (19% less procedure time/year of experience, 95% confidence interval [CI] 13%-25%, P <.001 in the PM subgroup; and 15% less procedure time/year of experience, 95% CI 7%-23%, P <.001 in the CRT subgroup). Fellow experience was associated with decreased fluoroscopy time in the CRT subgroup (19% less fluoroscopy time/experience years, 95% CI 5%-34%, P = .009). Neither fellow nor attending experience was associated with complications., Conclusion: Each year of fellow experience is associated with a decrease in cardiac device implantation procedure time and a decrease in fluoroscopy time during CRT implantation. No associations between fellow experience and in-hospital complications were observed., (© 2013 Heart Rhythm Society Published by Heart Rhythm Society All rights reserved.)

This paper provides an insight into Croatian health system with special focus on trauma care. The current situation is explained from a domestic point of view, but an independent review by foreign observers is also included. Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking of health care componenets into a unique chain of help. The concept and five methodological steps in the development of a succesfull trauma system are presented. A good start is definitely a reorganization of existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry as a standard for future discussion. Individual components of the trauma system can not be separately "optimized" so clinical and financial decisions should be planned exclusively on the integral level., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: This study aims to investigate the outcome of a two-stage surgery in the treatment of neglected femoral diaphyseal fractures which are not uncommon in developing nations., Patients and Methods: Ten patients with neglected or late-presenting femoral diaphyseal fractures were considered in this study. All patients underwent a two-stage surgery, which consisted of distraction by an external fixator and open reduction by internal plate fixation. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with radiographs at 2 months to assess union and at monthly intervals thereafter., Results: All patients achieved bony union in an average of 3.7 months (2-6 months) with no one lost follow-up. Seven patients regained full range of motion, and the mean knee range of motion was 139.5°. No wound related or neurovascular complications were detected. One patient with stiff knee was re-admitted 1 year after surgery for metal removal, arthrolysis and quadricepsplasty for improving knee range of motion to 90° flexion., Conclusions: We conclude that the treating of neglected femoral diaphyseal fractures with a two-stage surgery is a satisfactory therapy showing reliable bony union, however continuing medical education is necessary for physicians in primary medical facilities as well as for patients with traditional views., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Study Objective: To determine the attitudes and perceptions of diplomates of the American Board of Anesthesiology (ABA) regarding the value of Board certification, Maintenance of Certification (MOC),and the specific components., Design: Survey instrument., Setting: American Board of Anesthesiology, Raleigh, NC, USA., Subjects: Diplomates of the ABA., Measurements: A SurveyMonkey link was sent to 3,000 randomly selected 1) non-time-limited diplomates who were not enrolled in MOC, 2) non-time-limited diplomates who were enrolled in MOC, and 3) time-limited diplomates of the ABA (1,000 survey requests per group). The surveys queried demographics, attitudes about the value of Board certification, and attitudes and knowledge about Maintenance of Certification in Anesthesiology (MOCA)., Main Results: 17% to 27% of diplomates from each group completed the survey. The majority of these diplomates perceived Board certification to be of value in demonstrating competence, although fewer believed that Board certification reflected competence. The elements of Professional Standing and Lifelong Learning and Self-Assessment were perceived to be significantly more relevant to the practice of the diplomates than were the Cognitive Examination and Practice Performance Assessment and Improvement activities. Diplomates demonstrated concerns about the cost and complexity of MOC, a lack of evidence that it improves practice, and a belief that the Cognitive Examination covered topics that were not relevant to their current practice., Conclusions: Although diplomates of the ABA highly value Board certification and report that the components of the MOCA program have potential relevance to their practices, they expressed significant concerns about the program as it is currently implemented., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Electronic fetal monitoring during labor is the most commonly used method to evaluate the fetal status, but it remains exposed to some criticism. By comparison with intermittent auscultation and in the light of the results of the great studies in the last 30 years, it may be accused its failure to improve the neonatal outcome and its responsibility in the increase on operative deliveries. Actually, the electronic fetal monitoring is a tool whose effectiveness is linked to the accuracy of the analysis developed by the clinician. Studies on assessment of the tracing interpretation indicate that there is always a lack of quality, which may be improved through training programs. It also reveals the benefit of the fetal blood sampling to reduce operative deliveries and the generalization of this method, in addition to electronic fetal monitoring, is recommended by referral agencies. More generally, the continuous monitoring is only a part of the patient safety strategy in the labour ward and we are currently observing, in some European countries and in the United States, the development of training programs concerning the management of the adverse outcomes in obstetrics. The good performances related to the quality of care are demonstrated by the findings of the studies performed in the centers that have implemented an active training policy. In France, the professionals directly involved in the field of the perinatology should benefit from such educational programs that could be organized within the care networks under the authority of referral agencies., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Live case demonstrations (LCDs) are now prevalent in medical education courses despite ethical concerns including that they may expose patients to undue risk. However, there are limited data regarding many aspects of LCDs to help inform policies and guidelines regarding them., Methods: We conducted an Internet-based survey of clinicians who have served as faculty or attended the 2009 and 2010 professional meetings sponsored by VIVA (Vascular Interventional Advances)., Results: There were 106 VIVA 2009 respondents and 165 VIVA 2010 respondents. Observing an LCD was more valuable than watching a prerecorded video for most (70% in 2009; 82% in 2010) respondents. About one-third of respondents thought that LCD patients are exposed to more risk than non-LCD patients. Respondents who had been operators were more likely to agree that LCD patients are exposed to more risk (p = 0.001 in 2009; p = 0.022 in 2010). Approximately one-third of respondents in 2009 and one-half in 2010 thought that patients experience direct medical benefit in an LCD. The majority (71% in 2009; 76% in 2010) indicated that they would support the decision of a family member or friend to be an LCD patient, few (44% in 2009; 58% in 2010) indicated that they personally would agree to be an LCD patient., Conclusions: This survey provides new insights into the value and risk of LCDs. Obtaining the perspective of patients would be extremely valuable in helping to ensure that the ethical aspects of LCDs are addressed properly and thoroughly., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Calls for reform to postgraduate medical training structures in the UK have included suggestions that training should foster excellence and not simply ensure competence., Methods: We conducted a modified Delphi-type survey starting with an e-mail request to specialist anaesthetists involved in education, asking them to identify the attributes of an excellent anaesthetist. In focused group interviews, their coded and categorized responses were ranked, and suggestions were made for incorporation into anaesthesia education. We also compared the findings with currently available professional and educational guidance., Results: Our expert group strongly expressed the view that while superior knowledge and skills, associated with exceptional performance in clinical work, were fundamental to the excellent practitioner, they were not sufficient in themselves. A group of attributes that were personal qualities and functions of personality were also considered essential. The defining characteristic of excellence was, perhaps, the continuing urge to seek challenges and learn from them. Other high-ranking characteristics included clinical skills, interest in teaching, conscientiousness, innovation/originality, communication skills, and good relationships with patients. Knowledge for its own sake (personal involvement in research) was not rated highly, but applied knowledge was judged to underlie many of the most important categories., Conclusions: The achievement of excellence in anaesthesia is likely to depend on the successful interplay of individuals' personal qualities and the environment in which they work. Thus, not only trainees but also educational supervisors, heads of departments, and those responsible for organizing training systems all have a part to play in the encouragement of excellence.

The arguments in favour of recertification have been made cogently. Doctors in the UK on the whole continue to enjoy the trust and respect of their patients and the general public, but the Shipman enquiry led by Dame Janet Smith questioned the validity of the existing system. Following a lengthy discussion, the Chief Medical Officer of England published his proposal for professional regulation: Trust, assurance and safety - the regulation of health professionals in the 21st century¹ was published in February 2007. This document laid out the principles of revalidation for all doctors practising in the United Kingdom. The purpose of revalidation is principally to ensure that doctors update their knowledge and skills, and that they are fit to practise. This mechanism of revalidation will ensure that health professionals will be able to demonstrate their continued fitness to practise by collecting supporting data. The medical revalidation has two components: relicensure and specialist recertification. From 16 November 2009 all doctors are expected to have a licence to practise to enable them to remain on the Medical Register, and this licence must be renewed every year. This process will be managed by the General Medical Council (GMC). Recertification will apply to all specialist doctors, including general practitioners, requiring them to demonstrate that they meet the standards that apply to their particular medical specialty. The Royal Colleges have been delegated to set these standards, and approved by the GMC. Recertification will take place every five years. Recertification will be underpinned by enhanced appraisal, multi source feedback, and a robust continuing professional development programme., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Internet, unknown there fifteen years, has become commonly used today to communicate and exchange all types of information. Concerning medical points, this network is full of data and has become indispensable to physicians. The biomedical knowledge base is changing so fast that it is impossible for a doctor to know everything about everything. Specialists are increasingly specialized but must keep aware of developments in medical knowledge and above all must be able to search quickly and effectively in a given time. To stay informed, they have several means of which the most common are reading the press, Continuing Medical Education and now Internet. Unfortunately, the richness of the Web is also its main fault so we must have the knowledges for searching, analyzing, among the flood of documents available if we do not want to be caught by the screen. Internet usage is done by two approaches: the pull: dynamic approach to information retrieval and the push: passive process of receiving documents. Most doctors have not been trained to use this tool although it became their main source of knowledge and research. This article aims to outline the main ways to learn about a specific topic by giving some tips for saving time.

Examinees of the first Certifying Examination in Cardiovascular Computed Tomography were surveyed regarding their training and experience in cardiac computed tomography. The results support the current training pathways within the American College of Cardiology/American Heart Association competency criteria that include either experience-based or formal training program in cardiovascular computed tomography. Increased duration in clinical practice, the number of scans clinically interpreted in practice, and level 3 competency were associated with higher passing rates., (Copyright © 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (alpha=0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Vascular surgical specialisation is associated with improved outcomes. We aimed to assess the effect of anaesthetic specialisation on outcome following major vascular surgery., Design: Retrospective cohort study., Methods: Patients undergoing major vascular surgery (lower limb revascularisation, elective and ruptured abdominal aortic aneurysm repair, endovascular aneurysm repair and carotid endarterectomy) over a five-year period were identified from a prospective database. The primary outcomes were death within 30 days and death within two years of surgery. Potential risk factors for mortality were assessed using multivariate logistic regression modelling., Results: The analysis cohort comprised 1155 patients followed up for a median of 583 days. Mortality within two years of surgery was 16%. For the overall cohort, care from vascular anaesthetists was independently associated with reduced 30-day (odds ratio 0.22; 95% CI 0.12-0.62) and medium-term mortality (0.31; 95% CI 0.18-0.55). For elective patients (n=851), vascular anaesthesia reduced two-year mortality (odds ratio 0.29; 95% CI 0.15-0.58; P=0.0004) though not 30-day mortality (odds ratio 0.55; 95% CI 0.15-1.95; P=0.35). For emergency patients, care by a vascular anaesthetist influenced neither 30-day mortality (odds ratio 0.33; 95% CI 0.08-1.41; P=0.13) nor medium-term mortality (odds ratio 0.45; 95% CI 0.17-1.21; P=0.11)., Conclusions: Anaesthetic specialisation reduced early- and medium-term mortality rates following major vascular surgery. If replicated by prospective studies, these results suggest that vascular surgery services would benefit from specialised anaesthetic support., (Copyright (c) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)