Infection control education: impact on ventilator-associated pneumonia rates in a public sector intensive care unit in Pakistan

We describe efforts towards introducing infection control (IC) practices and establishment of antimicrobial resistance (AMR) surveillance in a public sector hospital in Pakistan. The study was conducted in an eight-bed intensive care unit. IC principles, introduced through interactive sessions, were used as an intervention and their impact was observed by conducting surveillance for ventilator-associated pneumonia (VAP) before and after the intervention. Respiratory isolates of VAP patients in the period after intervention were screened for AMR, and empiric antibiotic at the time of admission was compared with the antimicrobial sensitivity pattern reported. VAP rates were high in general and declined in the period after intervention, although the difference was not significant. Of 37 VAP patients in the period after intervention, 68% had more than one clinically significant organism isolated from the respiratory specimen. Acinetobacter spp. were isolated from 76% of patients and Pseudomonas aeruginosa from 43%. All Acinetobacter spp. and 72% P. aeruginosa were multidrug resistant. The mean stay of the nosocomially infected patients was significantly higher than for the uninfected group (6.5 vs. 2.1 days, P<0.001). Our study suggests IC education needs to be supplemented by a hospital system that facilitates IC practices and development of surveillance programmes.

Judging respiratory specimen acceptability for AFB microscopy: visual vs. microscopic screening

OBJECTIVES

To investigate whether visual assessment or microscopic grading of the cellular composition of specimens is a better strategy to screen specimen quality for tuberculosis (TB) diagnosis.

METHODS

About 2643 specimens were collected from TB suspects at the Federal TB centre in Pakistan. Specimens were classified as sputum or saliva visually and microscopically using the criteria proposed by McCarter and Robinson, Van Scoy, Geckler et al., Murray and Washington and Bartlett. The acid-fast bacilli (AFB)-positivity of specimens was also assessed. Results Despite being the least 'technical' and time consuming, visual assessment rejected the lowest proportion of AFB-positive specimens (0.3%). Most microscopic grading criteria, particularly those that considered the squamous epithelial cell count, rejected a large proportion of specimens (30-66%), of which a sizeable fraction contained AFB (6-12%).

CONCLUSIONS

Our results indicate that visual assessment by trained technicians is more effective and suitable than microscopic grading for screening specimens for TB diagnosis. TB control resources could be better allocated to optimizing visual screening than investing in more 'strict' microscopic grading tools.

Anti H.pylori IgM in symptomatic and asymptomatic population

To evaluate the usefulness of specific IgM in the diagnosis of Helicobacter pylori infection, a cross sectional study was carried out in the Department of Microbiology, Mymensingh Medical College between July 2006 to June 2007. A total of 45 patients having upper gastrointestinal symptoms underwent endoscopy and were subsequently diagnosed as patients with gastritis, peptic ulcer (PU) and non-ulcer dyspepsia (NUD) and another 45 asymptomatic individuals aged 18-65 years, were included in the study. The serum samples of participants were tested for presence of anti-H pylori IgM by using ELISA method. The ELISA for anti H. pylori IgM provided sensitivity and specificity of 73.33%, 93.33% respectively.

Ablative and reconstructive robotic-assisted laparoscopic renal surgery

INTRODUCTION

The increasing role of robotic technology to facilitate surgical procedures has attracted much attention from surgeons and patients alike. In particular, the dramatic increase in the number of laparoscopic radical prostatectomies performed using the da Vinci surgical system has led to interest in using this technology for other procedures. We have evaluated our own experience performing ablative and reconstructive laparoscopic renal surgery using the da Vinci system to determine its potential role.

AIMS

To review our experience of robotic-assisted laparoscopic procedures of the upper urinary tract.

MATERIALS AND METHODS

Our da Vinci system was installed in June 2004. A prospective database has been maintained concerning all patients and procedures performed from that time. Procedures involving the upper urinary tract were identified and the data was examined. This included patient demographics, operative time, blood loss, hospital stay and patient outcomes.

RESULTS

Twenty-six robotic procedures involved the upper urinary tract. Of these, two had to be converted to conventional laparoscopic surgery because of da Vinci mechanical failure. Robotic-assisted procedures included pyeloplasty (n = 15), simple nephrectomy (n = 2), radical nephrectomy (n = 1), nephroureterectomy (n = 2), and live donor nephrectomy (n = 4). The mean operative time was 215 min. The anastomotic time for the pyeloplasties averaged 47 min. The mean blood loss was 75 ml. There were no conversions to open surgery. The complication rate was 8.7%. Postoperative stay averaged 2.9 days.

CONCLUSION

The da Vinci surgical system may be safely used to assist in the performance of laparoscopic renal surgery.

Robotic assisted radical cystectomy: short to medium-term oncologic and functional outcomes

PURPOSE

To report short- and medium-term oncological and functional outcomes of the first robotic-assisted laparoscopic radical cystectomy (RARC) series from the UK.

MATERIALS AND METHODS

Thirty patients underwent RARC between 2004 and 2007 at our unit. We report oncological and functional outcomes of this procedure in 20 patients (17 ileal conduit and three Studer Pouches), who have completed at least 6 months of follow up.

RESULTS

There were 17 men and three women, median age 66 years (range 38-77 years). Median operating time was 330 min (range 295-510 min), and median blood loss 150 ml (range 100-1150 ml). There were two major complications (10%); a port site bleed and a rectal injury. The median follow up of this cohort is 23 months (range 7-44 months). One patient died of distant metastases at 8 months, and another developed a right ureteric tumour at 7 months. None of the patients had local pelvic or port site recurrence. The overall and disease-free survival are 95% and 90% respectively. Functional complications included a neovesico-urethral stricture at 3 months, a left upper ureteric stricture at 6 months and an incisional hernia at 12 months.

CONCLUSION

Robotic-assisted laparoscopic radical cystectomy is an emerging minimally invasive procedure which at short- to medium-term follow up, in our experience, is oncologically and functionally equivalent to open radical cystectomy.

Influence of number of retransplants on renal graft outcome

BACKGROUND

To assess the influence of number of transplants on the renal graft outcome.

METHODS

Retrospective analysis of various factors that could influence the outcome of kidney retransplantation in patients receiving more than one allograft between 1993 and 2005 at our center.

RESULTS

During the 12-year period (1993-2005), 196 patients received more than one renal transplant. Of these, 163 had two (group 1) and 33 had more than two transplants (group II). In group II, 24 patients had three, eight had four, and one had five consecutive allografts. The control group comprised of 100 randomly selected patients receiving a first graft during the same period. In group I, 53 (32.5%) grafts failed. Eighteen (11.0%) patients died with functioning grafts. In group II, 14 (41.2%) grafts failed while four patients (11.8%) died with functioning grafts. In group I, actuarial graft survival rates at 1, 2, 3, and 4 years were 82.3%, 67.3%, 55.97%, and 42.14%, respectively. In group II, the respective figures were 84.85%, 66.67%, 60.61%, and 51.52%. The difference was not statistically significant (P = .96). In the control group, 1-, 2-, 3-, and 4-year survival rates were 92%, 84, 74%, and 60%, respectively. The difference between the control and study groups was statistically significant (P = .0002).

CONCLUSION

Graft survival after retransplantation is relatively inferior when compared to the primary graft but still remains fairly high. Therefore, previous graft failure should not be considered as a relative contraindication for retransplantation.

The potential use of methotrexate in the treatment of falciparum malaria: in vitro assays against sensitive and multidrug-resistant falciparum strains

The anti-malarial activity of the anti-cancer drug methotrexate against chloroquine-sensitive T9-96 and the multidrug-resistant K1 strains of Plasmodium falciparum was assessed in vitro. Mean IC50 values of 0.32 +/- 0.05 nM and 48.02 +/- 4.40 nM were obtained for T9-96 and K1, respectively, indicating methotrexate's high potency against both sensitive and resistant P. falciparum strains in vitro. Our results suggest that methotrexate is potentially effective against falciparum malaria in short-term, low-dose regimens, minimizing the risk of toxicity. This, along with the practical advantages of methotrexate, warrants the clinical investigation of methotrexate in human cases of falciparum malaria.

Screening of free-living rhizospheric bacteria for their multiple plant growth promoting activities

Plant growth promoting rhizobacteria (PGPR) are known to influence plant growth by various direct or indirect mechanisms. In search of efficient PGPR strains with multiple activities, a total of 72 bacterial isolates belonging to Azotobacter, fluorescent Pseudomonas, Mesorhizobium and Bacillus were isolated from different rhizospheric soil and plant root nodules in the vicinity of Aligarh. These test isolates were biochemically characterized. These isolates were screened in vitro for their plant growth promoting traits like production of indoleacetic acid (IAA), ammonia (NH(3)), hydrogen cyanide (HCN), siderophore, phosphate solubilization and antifungal activity. More than 80% of the isolates of Azotobacter, fluorescent Pseudomonas and Mesorhizobium ciceri produced IAA, whereas only 20% of Bacillus isolates was IAA producer. Solubilization of phosphate was commonly detected in the isolates of Bacillus (80%) followed by Azotobacter (74.47%), Pseudomonas (55.56%) and Mesorhizobium (16.67%). All test isolates could produce ammonia but none of the isolates hydrolyzed chitin. Siderophore production and antifungal activity of these isolates except Mesorhizobium were exhibited by 10-12.77% isolates. HCN production was more common trait of Pseudomonas (88.89%) and Bacillus (50%). On the basis of multiple plant growth promoting activities, eleven bacterial isolates (seven Azotobacter, three Pseudomonas and one Bacillus) were evaluated for their quantitative IAA production, and broad-spectrum (active against three test fungi) antifungal activity. Almost at all concentration of tryptophan (50-500 microg/ml), IAA production was highest in the Pseudomonas followed by Azotobacter and Bacillus isolates. Azotobacter isolates (AZT(3), AZT(13), AZT(23)), Pseudomonas (Ps(5)) and Bacillus (B(1)) showed broad-spectrum antifungal activity on Muller-Hinton medium against Aspergillus, one or more species of Fusarium and Rhizoctonia bataticola. Further evaluation of the isolates exhibiting multiple plant growth promoting (PGP) traits on soil-plant system is needed to uncover their efficacy as effective PGPR.

Evolution of transdermal oxybutynin in the treatment of overactive bladder

Overactive bladder (OAB) syndrome affects millions of people worldwide. In addition to adversely affecting quality of life, the direct and indirect costs in managing patients with OAB incur a substantial financial burden on health services. Among the approved anticholinergics for treating OAB, oxybutynin is the most extensively studied drug in clinical trials. The principle metabolite of oxybutynin has a higher affinity for muscarinic receptors in salivary glands which lead to significantly high dry mouth rates. This prompted the development of alternative formulations of oxybutynin aiming to achieve better tolerability whilst sustaining efficacy. This editorial examines the efficacy and tolerability of transdermal oxybutynin (OXY-TD) in treating OAB. Articles were retrieved from PubMed between 2000 to the present day relating to OXY-TD. Data is presented from phase I-IV trials. The results from placebo-controlled trials indicate that OXY-TD is efficacious in treating patients with OAB associated with urge urinary or mixed incontinence. Systemic side effects most notably dry mouth, appear to be less with this formulation compared with oral anticholinergics. However, further study is required in different OAB populations. The main limitation appears to be related to application site adverse events such as pruritus and erythema. OXY-TD is likely to find its place as first-line pharmacotherapy in the clinicians' armamentarium in treating OAB.

Renal Vein Thrombosis

OBJECTIVE

The aim of this article is to review the published English literature on aetiology, pathology, clinical presentation, diagnostic methods and treatment of renal vein thrombosis.

MATERIALS AND METHODS

We searched the published literature from Medline & Pubmed using keywords renal vein thrombosis, anti-phospholipid syndrome and nephrotic syndrome. Data was extracted from individual case reports, case series, articles on pathology, diagnostic tests, treatment modalities, and previous reviews. Case reports which did not add any new information were excluded.

RESULTS

We selected 60 references based on the above criteria. Renal vein thrombosis is relatively rare. CT angiography is considered the investigation of choice. Alternatives include MR angiography or renal venography in highly selected patients. As the condition is relatively uncommon, consensus on the best form of therapy for this condition has been slow to evolve. The trend in management has shifted to non-surgical therapies particularly systemic anticoagulation except in highly selected group of patients.

Oral contraceptives in gall stone diseases

A cross sectional study was under taken to evaluate the prevalence of gallstone in fertile women who are taking oral contraceptives. The aim of study was to determine any significant association between oral contractive use and Cholelithiasis. Total number of patient was 340. A standard written questioner, which is dully filled by concerned doctor and examination done. History of use of oral contraceptive pills, duration of use and time of taking oral contraceptives drugs whether before, in between pregnancy or after family completion is recorded. Total number of patient was 340 of them 186 patient taken contraceptives and 154 patients without contraceptives. Incidence of gallstone shows that with contraceptives the 21-30 years age group 72(39.13%) without contraceptives 22(14.28%), in 31-40 years age group with contraceptives 74 (40%), without contraceptives 28(18.8%) where as in 41-50 years age group with contraceptives 37(20.10%) and without contraceptives 44(28.57%), 51 years and above age group with contraceptives is 01(0.54%) and without contraceptives is 60(38.96%). Significantly higher incidence of gallstones found in younger patient taking oral contraceptives than without contraceptives, but in older age group incidence is more in-patients without contraceptives than with contraceptives. Oral contraceptives increase the incidence of gallstones disease in younger women especially in early part of their use of oral contraceptives.

Robotic technology in urology

Urology has increasingly become a technology-driven specialty. The advent of robotic surgical systems in the past 10 years has led to urologists becoming the world leaders in the use of such technology. In this paper, we review the history and current status of robotic technology in urology. From the earliest uses of robots for transurethral resection of the prostate, to robotic devices for manipulating laparoscopes and to the current crop of master-slave devices for robotic-assisted laparoscopic surgery, the evolution of robotics in the urology operating theatre is presented. Future possibilities, including the prospects for nanotechnology in urology, are awaited.

Transplantation of kidneys from deceased adult polycystic donors

Renal transplantation is the best treatment for end-stage renal disease. The discrepancy between donor organ supply and demand continues to widen. Maximum efforts should be made to make use of donor kidneys and we suggest that polycystic kidneys can be suitable marginal donor organs. Five polycystic cadaveric donor kidneys were transplanted in four recipients at our institution between year 2000 and 2004. The donor kidneys were either of normal size or moderately enlarged (less than 15 x 10 cm). Donor ages were 24, 46 and 55 years. All donors had normal serum creatinine at the time of organ retrieval. Recipients gave informed consent to be transplanted with the polycystic kidneys. Three of four recipients had primary graft function. The patient with primary nonfunction required graft nephrectomy 8 weeks post-transplantation. One patient died due to cardiovascular causes with a functioning graft 18 months after transplantation. Two patients remain well, 26 and 58 months after transplantation, with normal graft function. Our experience and the limited evidence from the literature suggest that, with careful selection of both donor and recipient, transplantation of cadaveric polycystic donor kidneys should be considered given the current organ shortage.

A Yellow Mosaic Disease of Soybean in Northern India is Caused by Cotton leaf curl Kokhran virus

Soybean, Glycine max (L.) Merr., is a protein- and oil-rich crop cultivated in India and abroad. A yellow mosaic disease was observed on soybean with 80 to 90% disease incidence during August 2005 at fields of the National Botanical Research Institute, Lucknow, in northern India. Soybean plants were found to be infested with whiteflies (Bemisia tabaci) suggesting begomovirus etiology. The disease agent was transmitted experimentally by whiteflies, and symptoms developed after 23 days. Total DNA was isolated from 51 leaf samples collected from 42 symptomatic and 9 asymptomatic plants. Polymerase chain reaction was performed using begomovirus coat protein-specific primers 5'-ATGGCGAA GCGACCAG-3' and 5'-TTAATTTGTGACCGAATCAT-3' (AM180920/ AM180921). An amplicon of the expected size (~800 bp) was obtained in all 42 symptomatic leaves but not from any of the nine asymptomatic leaf samples. The amplicon was cloned, and the identical sequence of three clones was submitted to GenBank (Accession No. DQ343283). BLAST search of nucleotide sequences revealed 95% identity with Cotton leaf curl Kokhran virus (CLCKV) (GenBank Accession Nos. AJ002449, AJ002448, AJ496286, and AY456683) and 57% identity with Mungbean yellow mosaic India virus (MYMIV-Sb, GenBank Accession No. AY049772). Results indicated that the virus associated with yellow mosaic disease of soybean is an isolate of CLCKV rather than MYMIV-Sb (1) reported earlier on soybean from northern India. To our knowledge, this is the first report of soybean as a new host of Cotton leaf curl Kokhran virus. Reference: (1) K. S. Usharani et al. Curr. Sci. 86:845, 2004.

Current trends in the diagnosis and management of renal nutcracker syndrome: a review

Nutcracker syndrome is caused by compression of the left renal vein between the aorta and the superior mesenteric artery where it passes in the fork formed at the bifurcation of these arteries. The phenomenon results in left renal venous hypertension. The syndrome is manifested by left flank and abdominal pain, with or without unilateral haematuria. Other common presentation is as "pelvic congestion syndrome" characterized by symptoms of dysmenorrhea, dyspareunia, post-coital ache, lower abdominal pain, dysuria, pelvic, vulvar, gluteal or thigh varices and emotional disturbances. Likewise compression of the left renal vein can cause left renal-to-gonadal vein reflux resulting in lower limb varices and varicoceles in males. Its diagnosis is based on history and physical examination, basic lab tests to exclude other causes of haematuria, cystoscopy and ureteroscopy to confirm unilateral haematuria and exclude other causes of this sinister symptom. Sequence of imaging has more or less been rationalised to USS with Doppler studies, CT or MR angiography and finally phlebography with renal vein and IVC manometery to confirm the diagnosis.

Laparoscopic pyeloplasty and pyelopyelostomy for ureteropelvic junction obstruction in a duplicated collecting system

Ureteropelvic junction obstruction can be associated with renal anomalies. We present a case of symptomatic ureteropelvic junction obstruction associated with a duplicated collecting system that was successfully treated by laparoscopic pyeloplasty and concomitant pyelopyelostomy. The operative time was 210 minutes, and the blood loss was 20 mL. The inpatient stay was 4.5 days, and the patient returned to work after 28 days. Subsequent renograms confirmed improvement in renal function and resolution of obstruction. After 1 year, the patient remained asymptomatic. This is a feasible minimally invasive procedure for this condition that requires advanced reconstructive and intracorporeal suturing skills.

Occurrence of yellow mosaic geminiviral disease on bitter gourd (Momordica charantia) and its impact on phytochemical contents

Natural occurrence of yellow mosaic disease was observed on bitter gourd (Momordica charantia). Association of geminivirus with the disease was investigated through polymerase chain reaction using geminivirus-specific primers and Southern hybridization with a probe prepared from the cloned DNA of a known geminivirus. The fruits, leaves and stem of infected and healthy plants were studied for phytochemical composition. The amounts of protein were 49%, 50% and 66% higher, total carotenoids were 36%, 33% and 40% lower, vitamin C were 23%, 48% and 50% lower, total phenols were 28%, 31% and 43% lower, and antioxidant activity were 36%, 48% and 43% lower in the severely virus infected fruits, leaves and stem, respectively, as compared with healthy plants. The loss in the quantity of these phytochemicals was also observed even in mild infected plants, which further increased with the severity of the symptoms. Similarly, ethanol and 50% ethanol soluble extractive were also 25-43% lower in the fruits, leaves and stem of infected plants as compared with the healthy plants. A 45% and 54% lower caffeic acid, and 78% and 59% lower amounts of ferulic acid in the fruits and stem, respectively, and a 25% loss of gallic acid were noticed in the leaves of the severely infected plants.

Laparoscopic Management of Cryptorchidism in Adults

OBJECTIVES

Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group.

PATIENTS AND METHODS

Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition.

RESULTS

The mean age was 29 yrs (range: 19-36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice.

CONCLUSIONS

Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes.

Follow-up of polytetrafluoroethylene arteriovenous fistulae for haemodialysis

The polytetrafluoroethylene (PTFE) arteriovenous fistula allows vascular access for haemodialysis where a primary fistula or brachio-basilic vein transposition is not possible. We report patency rates and complications associated with these prosthetic grafts. Fifty-nine upper limb PTFE grafts in 48 patients were evaluated with a mean follow-up of 19 months (range 2-54 months). Three grafts (5%) were never used. The primary patency rate at 6 weeks was 90%. Cumulative secondary patency rates were 66% at 6 months, 36% at 12 months, 17% at 18 months, 3% at 24 months and 2% at 30 months. None of the grafts had remained patent at 3 years. Forty-six percent of the grafts studied thrombosed at least once and 32% became infected. Although the initial primary patency rate achieved compares favourably with that reported for brachio-basilic transposition fistulae, this study confirms that the use of prosthetic material is associated with a poor overall patency rate and high risk of complications. All options using autologous vein should be exhausted before considering prosthetic material.

Volvulus--a rare complication of ileal conduit

Conduit volvulus is a very rare complication of ileal conduit. To date, only seven surgically confirmed cases have been reported. Conduit volvulus is a potentially reversible cause of renal impairment in patients with urinary diversion. The diagnosis depends on accurate radiological evaluation. The length of the bowel to construct the ileal conduit, closure of defects around the conduit and its mesentery and retroperitonealization of ureteroileal anastomosis are the determining factors for such a complication.

Urinary tract infections: new insights into a common problem

This review discusses recent advances in the understanding of how the common pathogen, uropathogenic Escherichia coli, interacts with the host to lead to infection.

Eczema herpeticum: a case report

Primary herpetic gingivostomatitis is a relatively common and well-recognized condition that the dental practitioner may encounter in clinical practice. A primary herpetic infection in a child with atopic dermatitis such as eczema, however, predisposes them to eczema herpeticum. This can be a severe and potentially life-threatening condition. This paper describes one such case, discusses the aetiology, presentation and management of this condition, and highlights the importance of early recognition by the clinician.

Eosinophilic cystitis and its management

Eosinophilic cystitis (EC) is a rare clinicopathological condition characterized by transmural inflammation of the bladder predominantly with eosinophils, associated with fibrosis with or without muscle necrosis. The cause of EC remains unclear, although it has been associated with various aetiological factors, such as allergy, bladder tumour, bladder trauma, parasitic infections and chemotherapeutic agents. EC is, probably, caused by the antigen-antibody reaction. This leads to the production of various immunoglobulins, which, in turn, cause the activation of eosinophils and initiates the inflammatory process. The most common symptom complex consists of frequency, haematuria, dysuria and suprapubic pain. Cystoscopy and biopsy are the gold standard for diagnosis. Additional laboratory evidence supporting the diagnosis includes proteinuria, microscopic haematuria and peripheral eosinophilia, the last one occurring in few patients. There is no curative treatment for this condition. Current treatment modalities include transurethral resection of the bladder lesion along with non-specific medical therapy, such as non-steroidal anti-inflammatory agents or steroids. Because the lesion tends to recur in spite of the above therapy, long-term follow-up is mandatory.

Attitudes towards skills examinations for basic surgical trainees

Objective measures of surgical skill and cognition are becoming available. A questionnaire study examining surgeons' beliefs towards a skills-based examination, current standards and possible benefits was devised. Three hundred pairs of standardised anonymous questionnaires were sent to consultants and their basic surgical trainees (BSTs) irrespective of surgical specialty. Responses were requested using a Likert scale (1-5, 3=neutral response). Two-hundred and two replies were received (including 54 pairs). BST experience ranged from 6 to 60 months (mean 24 months). When questioned regarding current training in basic surgical skills, only 34% believed that they were given adequate training at present. Sixty-four per cent of respondents believed the introduction of a skills examination would raise standards and 66% believed it necessary. Eighty-three per cent of respondents believed that they or their BST would practice these skills, if an examination were introduced and 85% wanted or would provide dedicated teaching time for this. However, 68% had no access to a dedicated skills facility, and uptake of these, where available, was variable. When questioned about their ability to perform the six appropriate tasks, there was a poor correlation of scoring between the groups. Consultants and their BSTs do not believe that they are given adequate training in basic skills. The introduction of an examination would lead to practice of these skills and is seen as a positive move.