Hamish McKenzie

Molecular Epidemiology of Erythromycin Resistance in Streptococcus pneumoniae Isolates from Blood and Noninvasive Sites

ABSTRACT 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 MLSB isolates carried erm(B), and two isolates carried both erm(B) and mef(E). Fourteen of the 15 MLSB 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.

A randomised comparison of strategies for reducing infective complications of induced abortion

OBJECTIVES To determine lower genital tract carriage rates of C. trachomatis, N. gonorrhoeae and bacterial vaginosis among women seeking termination of pregnancy. To compare two clinical management strategies for minimising the risks of infective morbidity after induced abortion. DESIGN Prevalence of infections was assessed by screening women undergoing abortion. Clinical management strategies were compared by a randomised trial. SETTING The gynaecology departments of four hospitals in Scotland. PARTICIPANTS 1672 women undergoing induced abortion. INTERVENTIONS Women randomised to prophylaxis received metronidazole 1 g rectally before abortion plus doxycycline 100 mg twice daily for seven days. Women randomised to screen-and-treat received appropriate antibiotics only if screening proved positive for one or more infection. MAIN OUTCOME MEASURES Prevalences of infections; morbidity in the eight weeks following abortion as assessed by reported symptoms, general practitioner consultation and prescription rates and hospital re-attendances; costs to the NHS of alternative managements. RESULTS Prevalence rates: C. trachomatis 5.6%; N gonorrhoeae 0.19%; bacterial vaginosis 17.5%. Overall, women allocated to receive prophylaxis had lower rates of measures of short term infective morbidity than those allocated to screen-and-treat. These differences only reached statistical significance for women who were reported negative on screening. The direct costs to the NHS of prophylaxis and screen-and-treat were calculated to be 8.17 and 18.34 per woman, respectively. CONCLUSIONS Prevalences of lower genital tract infections which have been implicated in increased rates of infective morbidity after abortion are similar to those reported elsewhere. Universal antibiotic prophylaxis is at least as effective as a policy of screen-and-treat in minimising the risk of short term infective morbidity and is far more cost efficient.

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.

Undergraduate medical students' perceptions and expectations of theatre-based learning: How can we improve the student learning experience?

OBJECTIVE Much of the student experience in theatre depends on the interaction between student and surgeon, and having the opportunity to take part in procedures. Theatre-based teaching can be seen as having little inherent benefit otherwise. We wished to identify other factors contributing to the experience of theatre-based teaching. DESIGN A questionnaire survey, using forced-choice and open questions, of undergraduate medical students with experience of surgical attachments. SETTING AND PARTICIPANTS 54 final (5th) year medical students, University of Aberdeen. ANALYSIS Responses on the closed questions are presented as percentages. The themes arising from the open questions were identified and the relationships among these themes explored. RESULTS Student expectations of learning focused on knowledge acquisition. Students learning experiences varied widely, depending on how welcome they felt in theatre. Visibility and active participation influenced the experience. Students did not feel adequately prepared for getting the most out of this learning experience. CONCLUSIONS The student experience may be skewed by unrealistic expectations of theatre-based learning. Clear and realistic learning objectives, preparation in terms of familiarity with the environment and staff roles, embedding the experience in the patients journey/care pathways, faculty expectations being clearly communicated to clinical teaching staff and, perhaps above all, approachability of theatre staff are likely to improve the learning experience.

Which women should be tested for Chlamydia trachomatis

Objective To assess the prevalence of genitourinary Chlamydia trachomatis infection among women in different clinical settings, with a view to making decisions about who should be tested routinely.

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, womens views of screening were determined in the hospital‐based clinics.

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.

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 , 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 GMCs Tomorrows Doctors or the SDMCGs Scottish Doctor frameworks and those who are interested in education informatics in general.

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.

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.