Absence of chlamydial deoxyribonucleic acid from testicular and epididymal samples from men with obstructive azoospermia.

OBJECTIVE: To identify Chlamydia trachomatis DNA by polymerase chain reaction in the upper genital tract of men with obstructive azoospermia compared with men seeking vasectomy reversal. DESIGN: Case-control study. SETTING: Tertiary referral center, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. PATIENT(S): Cases were men with idiopathic obstructive azoospermia, and controls were men with azoospermia secondary to vasectomy. INTERVENTION(S): Chlamydia trachomatis-specific DNA test by polymerase chain reaction on testicular and epididymal biopsy samples, as well as epididymal aspirate. MAIN OUTCOME MEASURE(S): Presence of Chlamydia trachomatis DNA. RESULT(S): We did not detect the presence of Chlamydia trachomatis-specific DNA by polymerase chain reaction in the epididymis or testis of 36 asymptomatic men with obstructive azoospermia (14 cases, 22 controls). CONCLUSION(S): Our hypothesis that unrecognized, asymptomatic chlamydial infection will lead to complete bilateral obstruction of the male genital tract remains unproven.

A comparison of the United Kingdom clinical aptitude test (UK-CAT) with a traditional admission selection process.

BACKGROUND: The United Kingdom Clinical Aptitude Test (UK-CAT) was introduced for the purpose of student selection by a consortium of 23 UK University Medical and Dental Schools, including the University of Aberdeen in 2006. AIM: To compare candidate performance on UK-CAT with local medical student selection outcome. METHOD: We compared the outcomes of all applicants to Medicine, University of Aberdeen (UoA), in 2006 who undertook the UK-CAT. The candidates were selected into one of five outcomes (academic reject, reject following assessment, reject following interview, reserve list or offer). The candidate performance in the UK-CAT was compared to candidate performance on the UoA selection. RESULTS: Data are reported on 1307 (85.0%) students who applied to UoA in 2006 and undertook the UK-CAT. Total UK-CAT scores were significantly correlated with local selection scores. However, of 314 students offered a place following the conventional selection process, only 101 were also in the highest scoring 318 on the UK-CAT. CONCLUSIONS: Results from this study indicate that UK-CAT scores show weak correlation with success in our medical admissions process. It appears therefore that the UK-CAT examines different traits compared to our selection process. Further work is required to establish which better predicts success as an undergraduate or as a doctor.

Food-the way to a man's heart: a mini-case series of Campylobacter perimyocarditis.

Campylobacter jejuni enteritis is 1 of the most common causes of food poisoning. Although an infrequent complication, Campylobacter associated perimyocarditis can have fatal consequences. This article illustrates 2 cases. We examine the types of Campylobacter jejuni responsible and report the observed male preponderance of this complication.

A survey of clinical teaching fellowships in UK medical schools.

CONTEXT: Undergraduate medical education in the UK has changed considerably over the last decade. One development has involved the creation of teaching-specific posts for junior doctors by medical schools. These posts are generally termed 'clinical teaching fellowships', but it is not known how many of them exist, or whether they are similar in terms of educational activities, professional development, and research and clinical experience opportunities. METHODS: Teaching deans in all UK medical schools were sent a questionnaire relating to clinical teaching fellowships, and were asked to distribute a second set of different questionnaires to their clinical teaching fellows, which were to be returned to the authors separately. RESULTS: A total of 28 deans and 46 fellows responded. Fifteen medical schools had clinical teaching fellows and there appeared to be a total of 77 such posts in the UK. There was little uniformity in the activities undertaken within the posts. Deans who employed clinical teaching fellows were unanimously positive regarding the posts. Fellows were generally positive but expressed reservations relating to approval for postgraduate training, career development, deterioration in clinical skills, financial disincentives, credibility within one's own specialty, and provision of training and support. CONCLUSIONS: Clinical teaching fellow posts are generally enjoyed by fellows and valued by deans. Fellows carry out differing duties and their training in medical education is variable. The posts can be unstructured and may lack credibility to doctors outside medical education. Providing specific structured training in medical education, recognised at a national level, would help deal with these concerns.

Identifying the factors that determine feedback given to undergraduate medical students following formative mini-CEX assessments.

OBJECTIVE: We aimed to examine the factors that determine provision of feedback to students following mini-clinical evaluation exercise (mini-CEX) assessments. METHODS: We carried out a pilot study of all final year medical students at the University of Aberdeen between November 2005 and June 2006. The study involved 396 mini-CEX encounters (173 students and 105 assessors). We retrospectively analysed the components of feedback recorded on the marking sheets. Each component of feedback was coded as a binary response (feedback recorded or not). Logistic regression was used to determine the degree and significance of the factors that influenced feedback. Specialty block, range of marks, assessor group and assessor satisfaction were entered into the analysis using SPSS Version 14. RESULTS: The provision of feedback by our assessors was poor. In 22.7% of cases, positive features were not identified; in 28.2% of cases, no suggestions for development were highlighted; in 49.7% of cases, no action plan was formulated. Assessors who gave a wider range of scores for the specific skill domains were more likely to record areas for development and action plans. Specialty block influenced feedback on areas for development. Suggesting an action plan was significantly associated with assessor group, and academic trainees were the most consistent providers of feedback. Assessor satisfaction was significantly associated with highlighting 'anything especially good'. CONCLUSIONS: Numerous factors were associated with the provision of feedback in our cohort. Assessor training may address this variability. However, this would limit the diversity of assessors, which may be undesirable. More research is required on assessor training and recruitment.

How can we prepare medical students for theatre-based learning?

CONTEXT: The quality of medical undergraduate operating theatre-based teaching is variable. Preparation prior to attending theatre may support student learning. Identifying and agreeing key skills, competences and objectives for theatre-based teaching may contribute to this process of preparation. METHODS: We carried out a cross-sectional survey of consultant surgeons and students using a forced choice questionnaire containing 16 skills and competences classified as 'essential', 'desirable' or 'not appropriate', and a choice of 6 different teaching methods, scored for perceived effectiveness on a 5-point Likert scale. Questionnaire content was based on the findings from an earlier qualitative study. RESULTS: Comparative data analyses (Mann- Whitney and Kruskal-Wallis tests) were carried out using SPSS Version 14. A total of 42 consultant surgeons and 46 students completed the questionnaire (46% and 100% response rates, respectively). Knowledge of standard theatre etiquette and protocols, ability to scrub up adequately, ability to adhere to sterile procedures, awareness of risks to self, staff and patients, and appreciation of the need for careful peri-operative monitoring were considered 'essential' by the majority. Student and consultant responses differed significantly on 5 items, with students generally considering more practical skills and competences to be essential. Differences between students on medical and surgical attachments were also identified. CONCLUSIONS: Consultant surgeons and medical students agree on many aspects of the important learning points for theatre-based teaching. Compared with their teachers, students, particularly those on attachment to surgical specialties, are more ambitious - perhaps overly so - in the level of practical skills and risk awareness they expect to gain in theatre.

Core undergraduate psychiatry: what do non-specialists need to know?

OBJECTIVE: The purpose of this study is to define the most relevant topics for inclusion in an undergraduate psychiatric curriculum by asking non-psychiatrists what knowledge, skills and attitudes related to psychiatry they need in their day-to-day practice. METHODS: A questionnaire study involving non-psychiatric doctors (based both in hospitals and general practice) was carried out using Delphi methodology in 2 waves. In the first wave, 408 doctors described the psychiatric competencies they required in their current posts. From this, a list of 101 psychiatric topics was generated. In the second wave, 867 doctors rated these topics according to the relevance of each topic to their practice. RESULTS: Depression, alcohol misuse and drug misuse were rated as most relevant. General practitioners found more topics relevant to their practice than did hospital doctors, and there were disparities in the relative importance that the 2 groups gave to topics. CONCLUSIONS: This study demonstrates a systematic method for developing core curricular undergraduate learning objectives in a specialty area by asking doctors outside that specialty to identify topics that are relevant to their practice. Similar methods could be used for a range of specialties other than psychiatry and could provide a rational and transparent means of developing a core curriculum for medical students, when combined with perspectives from other sources.

Cross-referencing the Scottish Doctor and Tomorrow's Doctors learning outcome frameworks.

Learning outcomes, organised into systems or frameworks which describe and define the output of an educational programme, are being created and used in healthcare education with increasing frequency (Harden 2001, 2002). Medical schools may be required to conform to more than one such outcome framework. For example, both the UK General Medical Council (GMC) and the Scottish Deans' Medical Curriculum Group (SDMCG) have created and published a systematic learning outcome framework for medical graduates. Although both of these publications are concerned with undergraduate medical education, they differ in their aims, and structure. In order to use, evaluate and validate them, a cross-referencing system which relates each learning outcome statement, term or groups of terms is required. This paper describes the cross-referencing exercise undertaken by the SDMCG, the philosophy behind it, the practical steps taken, the findings, the lessons learnt and reflections upon how this work may be taken forward. It will be of interest to all those who are involved in curriculum development using outcomes, and especially those who use the GMC's Tomorrow's Doctors or the SDMCG's Scottish Doctor frameworks and those who are interested in education informatics in general.

Molecular epidemiology of macrolide resistance in beta-haemolytic streptococci of Lancefield groups A, B, C and G and evidence for a new mef element in group G streptococci that carries allelic variants of mef and msr(D).

OBJECTIVES: To study the molecular mechanisms of erythromycin resistance in beta-haemolytic streptococci of Lancefield groups A, B, C and G. METHODS: Erythromycin-resistant clinical isolates from North East Scotland were collected over 2 years. Resistance phenotypes were determined by disc diffusion and MICs by Etest. Resistance genes mef, msr(D), erm(B) and erm(TR) were identified by PCR and mef and msr(D) were sequenced. RESULTS: Erythromycin resistance prevalence was 1.9% in group A streptococci (31 of 1625), 4.3% in group B (53 of 1233), 3.8% in group C (18 of 479) and 6.2% in group G (64 of 1034). The numbers of resistant isolates available were 26, 42, 9 and 52 in each group respectively. The majority of resistant isolates in groups A (57.7%, 15 of 26), B (88.1%, 37 of 42) and G (90.4%, 47 of 52) were MLS(B). The contribution of M phenotype was significant in groups C (77.8%, 7 of 9) and A (42.3%, 11 of 26). Group A isolates carried mef(A) and group B carried mef(E) exclusively. A mef sequence distinct from mef(A) and mef(E) was identified in group G and was associated with a new msr(D) sequence. These sequence variants appear to be part of a new genetic element that is inserted in the comEC gene. A bimodal distribution of erythromycin MICs was noted in erm(TR) isolates. CONCLUSIONS: The results demonstrate significant differences in the mechanisms of macrolide resistance amongst different Lancefield groups in the same geographical area. New sequences show that resistance mechanisms are still evolving.

An evaluation of economics and acceptability of screening for Chlamydia trachomatis infection, in women attending antenatal, abortion, colposcopy and family planning clinics in Scotland, UK.

OBJECTIVE: The aims of this study were to determine cost effectiveness of screening for Chlamydia trachomatis in hospital-based antenatal and gynaecology clinics, and community-based family planning clinics. Additionally, women's views of screening were determined in the hospital-based clinics. DESIGN: Cost effectiveness based on decision model. Model probabilities were generated for a hypothetical sample of 250 women in each age group in each setting, based on prevalence studies, published data and expert opinion. A prospective observational study was used to generate data on prevalence and acceptability. SETTING: Antenatal, gynaecology and family planning clinics in Aberdeen, Edinburgh and Glasgow. SAMPLE: Prevalence was estimated in 2817 women. Acceptability was determined in 484 women. METHODS: An economic evaluation was performed using prevalence data from this and a previous study, and using outcome data from the literature and observational work. Incremental cost effectiveness ratios were estimated for each age group and clinical setting. Sensitivity analyses were performed to determine the robustness of incremental cost effectiveness ratios to changes in the incidence of long term sequelae and costs. The prevalence of infection was determined by nucleic acid amplification of urine samples or endocervical swabs. Knowledge of C. trachomatis and women's views of screening were determined using structured questionnaires. MAIN OUTCOME MEASURES: Direct health service costs of screening, incidence and costs associated with adverse sequelae, women's views of screening and prevalence of infection. RESULTS: The estimated cost of screening 250 women in each age group in each the four sample populations (total population of 3750) is 49,367 UK pounds, while preventing 64 major sequelae. This represents a net cost of 771.36 UK pounds in preventing one major sequela. Selective screening of all women under 20 years and all patients attending abortion clinics were shown to be the most cost effective strategies. These results were relatively insensitive to changes in estimated parameters, such as uptake rate, probabilities and unit costs of all major sequelae averted. Prevalence (95% CI) of infection in the highest risk groups (those aged under 20 in both antenatal and abortion clinics) was 12.1% (8.6-16.7) and 12.7% (7.3-21.2), respectively. The majority (>95%) of women agreed with a policy of regular screening for C. trachomatis, and screening in the settings employed in this study was largely acceptable. CONCLUSIONS: A single episode of screening for C. trachomatis does not result in net cost savings. Currently recommended strategies of screening for C. trachomatis in women under 25 years of age in abortion clinics are supported by our data on prevalence and acceptability. These data also suggest that hospital-based screening strategies should be further extended to include younger women attending antenatal clinics and all women of reproductive age attending colposcopy clinics.

Can history, ultrasound, or ELISA chlamydial antibodies, alone or in combination, predict tubal factor infertility in subfertile women?

BACKGROUND: This study aimed to determine whether medical history, transvaginal ultrasound (TVU) or Chlamydia trachomatis antibody testing (CAT), alone or in combination, could provide a non-invasive, clinically useful screening test for predicting tubal factor infertility (TFI) in subfertile women. METHODS: Prior to tubal evaluation, relevant medical history, TVU findings, and enzyme-linked immunosorbent assay (ELISA) IgG CAT results were collected. Sensitivity, specificity, likelihood ratios (LR) and accuracy for predicting TFI, as determined by laparoscopy and dye hydrotubation, were calculated for each test alone, and in parallel and series combination. RESULTS: Thirty per cent (63/207) were diagnosed with TFI. The highest sensitivity (67%, 95% CI: 54-77) included any positive test, yet missed one in three women with TFI. The highest specificity (100%, 95% CI: 97-100) required all three tests positive, but identified only three women. Only the combination of CAT and TVU rated as a good clinical test, but confidence intervals were wide due to the small numbers affected. The combination of CAT or TVU and CAT alone reported the highest accuracy (73%, 95% CI: 66-78), misdiagnosing one in four women. CONCLUSION: Medical history, TVU appearances, and ELISA IgG CAT alone, or in combination, failed to predict accurately TFI in subfertile women.

Parallel observation of four methods for screening women under 25 years of age for genital infection with Chlamydia trachomatis.

OBJECTIVES: To compare four methods of screening women for Chlamydia trachomatis in an obstetrics and gynaecology department. STUDY DESIGN: A total of 303 healthy women under 25 years were recruited from antenatal, induced abortion, and family planning clinics. Each underwent parallel testing of endocervical specimens by enzyme immunoassay (EIA) and ligase chain reaction (LCR), vulval swabs by LCR, and urine by LCR. Outcome measures included sensitivity, specificity, acceptability of each method, and the influence of pregnancy. RESULTS: Overall prevalence (95% CI) was 9.9% (6.8-14%). All methods had a high rate of detection (75-100%), not affected by pregnancy. Urine was most acceptable, followed by vulval swabbing. CONCLUSIONS: Opportunistic screening of women under 25 years attending obstetric and gynaecology affiliated clinics found high rates of C. trachomatis infection. Both urine and vulval swab methods were highly sensitive, acceptable, and not affected by pregnancy status. Due to pragmatic issues surrounding the urine method, screening by vulval swabs deserves wider recognition.

Molecular epidemiology of erythromycin resistance in Streptococcus pneumoniae isolates from blood and noninvasive sites.

Erythromycin-resistant isolates of Streptococcus pneumoniae from blood cultures and noninvasive sites were studied over a 3-year period. The prevalence of erythromycin resistance was 11.9% (19 of 160) in blood culture isolates but 4.2% (60 of 1,435) in noninvasive-site isolates. Sixty-two of the 79 resistant isolates were available for study. The M phenotype was responsible for 76% (47 of 62) of resistance, largely due to a serotype 14 clone, characterized by multilocus sequence typing as ST9, which accounted for 79% (37 of 47) of M phenotype resistance. The ST9 clone was 4.8 times more common in blood than in noninvasive sites. All M phenotype isolates were PCR positive for mef(A), but sequencing revealed that the ST9 clone possessed the mef(A) sequence commonly associated with Streptococcus pyogenes. All M phenotype isolates with this mef(A) sequence also had sequences consistent with the presence of the Tn1207.1 genetic element inserted in the celB gene. In contrast, isolates with the mef(E) sequence normally associated with S. pneumoniae contained sequences consistent with the presence of the mega insertion element. All MLS(B) isolates carried erm(B), and two isolates carried both erm(B) and mef(E). Fourteen of the 15 MLS(B) isolates were tetracycline resistant and contained tet(M). However, six M phenotype isolates of serotypes 19 (two isolates) and 23 (four isolates) were also tetracycline resistant and contained tet(M). MICs for isolates with the mef(A) sequence were significantly higher than MICs for isolates with the mef(E) sequence (P < 0.001). Thus, the ST9 clone of S. pneumoniae is a significant cause of invasive pneumococcal disease in northeast Scotland and is the single most important contributor to M phenotype erythromycin resistance.