Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward

Formal training in the subspecialty of pediatric anesthesiology began >60 years ago. Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the Accreditation Council on Graduate Medical Education (ACGME) and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm. As with all ACGME-accredited specialties, education leaders in pediatric anesthesiology first convened in 2014 to design specialty-specific developmental trajectories within the framework of the 6 core competencies, known as milestones, on which fellows were to be tracked during the 1-year fellowship. With 5 years of implementation, and substantial data and feedback, it has become clear that an iterative improvement was necessary to mirror the evolution of the profession. It was evident that the community required brevity and clarity in the next version of the milestones and required additional resources for assessment and faculty development. We describe here the methodology and considerations of our working group, guided by ACGME, in the rewriting of the milestones. We also provide suggestions for implementation and collaboration to support the education and assessment of pediatric anesthesiology fellows across the country.

External quality assessment of antimicrobial susceptibility testing in Europe

Comparability of results of antimicrobial susceptibility testing is essential for resistance surveillance studies. As different methods may be used in different countries, there may be particular problems with international comparisons of resistance rates. Data from external quality assessment (EQA) surveys participated in by laboratories from several European countries allow comparison of performance between countries. In this study, success rates with organism-antimicrobial agent combinations known to be difficult to test were examined. With penicillin resistance in pneumococci; vancomycin and high-level gentamicin resistance in enterococci; ampicillin, co-amoxiclav and chloramphenicol resistance in Haemophilus influenzae and methicillin resistance in staphylococci there were differences between countries in success rates for discrimination of resistant strains. This study suggests that differences between countries in rates of resistance for some organism-antimicrobial agent combinations should be interpreted with caution. International EQA is useful in the demonstration and clarification of such differences.

Antimicrobial susceptibility testing of enterococci: results of a survey conducted by the United Kingdom National External Quality Assessment Scheme for Microbiology

Six strains of enterococci were distributed to participants in the United Kingdom National External Quality Assessment Scheme for Microbiology with a request that they be tested for susceptibility to ampicillin/penicillin and vancomycin and for high-level resistance to gentamicin. More than 98% of laboratories correctly reported the resistant strains as resistant to penicillin and ampicillin. However, there was a poorer correlation for the susceptible strains, with only 1-6% and 69-83% of laboratories reporting the strains as susceptible to penicillin and ampicillin respectively. Those laboratories which used 5-25 micrograms ampicillin discs or breakpoint methods reported proportionally more results correctly for the susceptible strains than those using 2 micrograms discs. Participants using Escherichia coli or an enterococcus as a control and those not using a control at all were more likely to report ampicillin-susceptible strains correctly than those using Staphylococcus aureus NCTC 6571 (Oxford strain). For vancomycin-susceptible and high-level vancomycin-resistant strains, 93-96% and 96-99% of reports respectively were correct. For the low-level vancomycin-resistant strains, only 50-54% of reports were correct. Participants using a 5 micrograms vancomycin disc reported proportionally more of the low-level resistant strains correctly than those using 10, 20, 25, 30 or 100 micrograms discs. Participants not using controls were proportionally more likely to report the low-level resistant strains as susceptible than those using an enterococcus or S. aureus NCTC 6571 as a control. For the high-level gentamicin-resistant (HLGR) strains, 96-98% of reports were correct. Depending on the strain, between 12% and 41% of participants also reported high-level resistance for the strains which were not HLGR. Those using low-content discs (< or = 30 micrograms) and breakpoint or MIC methods were more likely to report strains which were not HLGR as HLGR than those using high-content discs. Those using an enterococcus as a control were less likely to report strains which were not HLGR as HLGR than those using either S. aureus NCTC 6571 or E. coli as a control and those not using a control.

Parasitology: United Kingdom National Quality Assessment Scheme

AIMS

To assess the results from parasitology laboratories taking part in a quality assessment scheme between 1986 and 1991; and to compare performance with repeat specimens.

METHODS

Quality assessment of blood parasitology, including tissue parasites (n = 444; 358 UK, 86 overseas), and faecal parasitology, including extra-intestinal parasites (n = 205; 141 UK, 64 overseas), was performed.

RESULTS

Overall, the standard of performance was poor. A questionnaire distributed to participants showed that a wide range of methods was used, some of which were considered inadequate to achieve reliable results. Teaching material was distributed to participants from time to time in an attempt to improve standards.

CONCLUSIONS

Since the closure of the IMLS fellowship course in 1972, fewer opportunities for specialised training in parasitology are available: more training is needed. Poor performance in the detection of malarial parasites is mainly attributable to incorrect speciation, misidentification, and lack of equipment such as an eyepiece graticule.

WHO international quality assessment scheme for HIV antibody testing: results from the second distribution of sera

The WHO international quality assessment scheme for human immunodeficiency virus (HIV) antibody testing has been established to monitor the quality of laboratory performance in testing for antibodies to HIV. Following a small trial distribution of specimens early in 1989, the second distribution was made in February 1990. A total of 20 specimens of sera, 10 of which contained antibodies to HIV-1, were sent to 103 laboratories located in the six WHO Regions. Participants were asked to test the specimens using their routine methods and to report to WHO their findings on each specimen for each diagnostic assay used and their interpretation of the HIV antibody status of each specimen. For the antibody-positive specimens, 98.2% of the results were interpreted as positive and 1.8% as indeterminate; no false-negative interpretations were reported. For the antibody-negative specimens, 90.3% of the results were interpreted as negative, 1.3% as positive, and 8.4% as indeterminate. Most of the indeterminate reports were associated with one particular specimen. A wide variety of diagnostic assays and combinations of assays were used. In terms of the technical results obtained rather than their interpretation, the assays appeared extremely reliable for the positive specimens, with 99.5% of assay results being recorded as positive, 0.17% as negative, and 0.34% as indeterminate.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of chloramphenicol resistance in Haemophilus influenzae

An average of 358 (13%) of United Kingdom laboratories failed to detect resistance to chloramphenicol in strains of Haemophilus influenzae distributed by the United Kingdom National External Quality Assessment Scheme for Microbiology. Clear associations between methods used and results obtained show that error rates are minimised by the use of low content (10 micrograms) disc and a sensitive control strain of H influenzae.

World Health Organization quality assessment programme on HIV testing

A serum panel comprising 19 samples of known (five positives and 14 negatives) but undisclosed HIV-1-antibody content was distributed to 30 national reference laboratories for HIV serology. In order to simulate normal circumstances of referral, participants were asked to test the panel for HIV-1-antibody status using their normal procedures. Results of testing were returned by 28 participants. There were great variations in the number and combinations of tests used. The number used ranged from one to five assays per laboratory and none of the 24 laboratories using two or more tests employed the same combination. A high average success rate of 99% was seen with the positive samples. More errors occurred with the negative samples, with an average of 87% correct negative reports. Only four of the 14 negative specimens were reported as negative by all participants.

Mycology quality assessment: United Kingdom national scheme

A mycology quality assessment scheme introduced in 1986 was assessed: 289 laboratories participated in the scheme, and six distributions, each containing four specimens, were made. Levels of performance varied considerably among participating laboratories: performance was highest with the commoner organisms distributed, but some laboratories, encouragingly, achieved a consistently high level of species identification. A questionnaire distributed to participants showed that a wide range of methods are commonly used, some of which are contrary to good practice. As the scheme continues, selection of organisms considered to be relevant and of use to participants will become difficult.

Antimicrobial susceptibility testing of Streptococcus pneumoniae: quality assessment results

Six strains of Streptococcus pneumoniae were distributed to 405 United Kingdom laboratories who were asked to test the susceptibility of the strains to penicillin, tetracycline, chloramphenicol and erythromycin and to provide details of methodology to test the standards of susceptibility testing. High error rates were seen only in failure to detect moderate resistance to penicillin (12%) and resistance to chloramphenicol (16%). Increased error rates were associated with several methods or practices. These included the use of certain culture media; failure to standardise the inoculum; inoculation by loop rather than by swab; failure to use control organisms; failure to measure zone sizes; the use of discs containing a high content of penicillin to test susceptibility to penicillin, and the use of high content discs for testing erythromycin, tetracycline, and chloramphenicol.

Antimicrobial susceptibility testing of Neisseria gonorrhoeae: a trial organised as part of the United Kingdom national external quality assessment scheme for microbiology

Six strains of Neisseria gonorrhoeae were distributed to 411 United Kingdom laboratories who were asked to test the susceptibility of the strains to penicillin, cefuroxime, tetracycline and spectinomycin and to test for production of beta-lactamase. Details of methods used were requested by means of a questionnaire. The number of reports recording sensitive strains as resistant was 5% for penicillin, 0.7% for cefuroxime, 3% for tetracycline and 4% for spectinomycin. The number of reports recording resistant strains as sensitive was 7% for penicillin (0.2% with beta-lactamase producing strains, 20% with non-beta-lactamase producing strains), 96% for cefuroxime, 76% for tetracycline and 8% for spectinomycin. There was an association between greater error rates and the use of high content discs for testing tetracycline, the use of low content discs for testing spectinomycin, failure to dilute the inoculum, and use of acidimetric methods rather than methods that use a chromogenic cephalosporin for detecting beta-lactamase.

Antimicrobial susceptibility testing of Haemophilus influenzae: trial organised as part of United Kingdom national external quality assessment scheme for microbiology

Six strains of Haemophilus influenzae were distributed to 417 United Kingdom laboratories who were asked to test susceptibility of the strains to ampicillin, augmentin, tetracycline, chloramphenicol, and trimethoprim and to test for beta lactamase production. Laboratories were also asked to provide details of their methods by completing a questionnaire. The incidence of reports recording sensitive strains as resistant was 8% (ampicillin), 7% (augmentin), 3% (tetracycline), 1% (chloramphenicol), and 12% (trimethoprim). The incidence of reports recording resistant strains as sensitive was 9% (ampicillin), (2% with beta lactamase producing strains, 24% with non-beta lactamase producing strains), 51% (augmentin), 10% (tetracycline), 20% (chloramphenicol), and 3% (trimethoprim). High error rates were associated with several methods or practices. These included use of general purpose growth media rather than susceptibility testing media and failure to add lysed blood to the media when testing trimethoprim susceptibility; standardise the inoculum; use suitable control strains; and the use of high content discs for testing chloramphenicol, tetracycline, and ampicillin.

Preparation of simulated clinical material for bacteriological examination

The preparation of mixtures of bacteria to mimic the flora found in pathological material is described. Such mixtures are useful for teaching, for practical examinations, for quality control of media and methods and for use in quality assessment schemes. The design of suitable mixtures is discussed and the stabilities of mixtures in transport media and in freeze-dried preparations are compared. Transport media provide short term storage for periods of several weeks and, with various modifications, are moderately successful with some, but not all, quite delicate pathogens. Freeze-drying however, provides greater stability over periods of months, allows preservation of delicate pathogens and is the preferred method where specimen quality is important.

United Kingdom scheme for external quality assessment in virology. Part I. General method of operation

Developments in the United Kingdom national external quality assessment scheme for virology are described. There are about 198 participants (170 in the UK) who are enrolled for examination of any or all of five categories of specimen (distribution types). These are detection of rubella antibody (128 UK participants), detection of hepatitis B surface antigen (130 UK participants), general virus serology (86 UK participants), virus identification (85 UK participants), and electron microscopy (56 UK participants). Specimens of a sixth category (rubella IgM antibody), not yet formally established, have also been distributed to 67 UK participants. Specimens in each distribution type are sent out once or twice a year, and, except for rubella IgM antibody, participants have been given a score of 2, 1, 0 or -1 marks for their reports on each specimen. Their cumulative scores and performance ratings are calculated retrospectively over a 12 month period for each distribution type separately and for combined distributions. The performance rating is defined by the number of standard errors by which the individual's cumulative score differs from the mean for all participants and carries a + or - sign depending on whether the cumulative score lies above or below the mean. Performance ratings have been found generally to be close to the mean in rubella serology and detection of hepatitis B surface antigen but are more variable in virus identification and electron microscopy. Ratings of less than -1.96 are considered to be significantly worse than average and to constitute poor performance.

Comparison of antibiotic susceptibility results obtained with Adatab and disc methods

Strains of Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, faecal streptococci, Proteus spp, and Klebsiella spp were distributed on two occasions to two groups of laboratories, one using a commercially produced break point method (Adatab, Mast Laboratories Ltd) and the other using a disc method for susceptibility testing. Minimum inhibitory concentrations of a range of antibiotics were determined for each of the strains in the Division of Microbiological Reagents and Quality Control and a correct result of sensitive or resistant was assigned where possible to each combination of strain and antibiotic. Laboratories were asked to determine the susceptibility of the strains to those antibiotics that they would test in routine practice. Results from each laboratory were compared with the correct results. The overall error rates obtained with the Adatab and disc methods, 8% and 8.2% respectively, were not significantly different. Fewer errors were made with trimethoprim, ticarcillin, and nitrofurantoin by laboratories using Adatabs than those using discs. Fewer errors were made with gentamicin by laboratories using discs than those using Adatabs. There was no significant difference between the two groups of laboratories in reproducibility of results on repeated testing of the same strains. Laboratories using Adatabs used a wide range of different break point concentrations. The Adatab method appeared to offer no overall advantages in terms of reduced error rates or increased reproducibility of results with the strains tested.

Detection of toxin production by Corynebacterium diphtheriae: results of a trial organised as part of the United Kingdom National External Microbiological Quality Assessment Scheme

Four strains of Corynebacterium diphtheriae were sent to UK participants in the UK National External Microbiological Quality Assessment Scheme, who were asked to examine the strains for toxin production by in vitro methods. Laboratories achieved 162/176 (92%) and 160/175 (91%) correct results with two rapid toxin producers and 145/175 (82%) with a slow toxin producer. With a non-toxigenic strain 26/175 (15%) laboratories reported toxin production. Of the 173 laboratories reporting on all four strains, only 120 (69%) achieved the correct result for all. There was no significant association between the use of various methods and results, with the exception that laboratories using a full set of positive, weak positive, and negative controls made fewer errors than those not using controls. A number of unsatisfactory practices were revealed by the trial, however, and recommendations on preparation of inoculum, media, peptones, animal sera, and use of controls are made.

Comparison of results from two antibiotic susceptibility testing trials that formed part of the United Kingdom national external quality assessment scheme

A susceptibility testing trial that formed part of the United Kingdom national external quality assessment scheme has been described previously. Results from this first trial showed an association between error rates and particular methods and practices. Changes in methods were recommended where appropriate. A second trial and survey of methods has shown reluctance to change methods and confirmed in most cases that high error rates were associated with the same methods and practices indicated by the first trial. Recommendations on disc content, method of methicillin testing, preparation of inoculum, use of controls and use of lysed blood for sulphonamide testing based on the results from these two trials are restated to encourage laboratories to review their methods critically. A statistical analysis of the results showed significant differences in performance among laboratories, and laboratories whose performance was significantly below the mean were identified. Poor performance was associated with the use of unsatisfactory methods. In view of the critical importance of susceptibility testing in patient care it is intended to use the results of susceptibility testing in the assessment of the performance of laboratories participating in the UK national external quality assessment scheme.

An antibiotic susceptibility testing trial organised as part of the United Kingdom national external microbiological quality assessment scheme

Organisms of known susceptibility to antimicrobial drugs were distributed for sensitivity testing to laboratories participating in the United Kingdom National External Microbiological Quality Assessment Scheme. The results obtained were correlated with the methods used. Laboratories differed in their standards of antimicrobial drug sensitivity testing. An association between error rates and particular methods and practices enabled recommendations to be made on disc content, method of methicillin testing, preparation of inoculum, use of controls and use of lysed blood for sulphonamide testing. Some media appeared significantly better than others but because of the many factors involved further information is being sought to clarify this.

The United Kingdom national microbiological quality assessment scheme

A comprehensive microbiological quality assessment scheme for the benefit of all clinical microbiological laboratories in the United Kingdom was established in 1974. The main emphasis of the scheme has been on the supply of simulated clinical material for proficiency testing. Of 494 laboratories currently participating in the scheme, 84 are abroad and over 500 specimens have been distributed between 1974 and 1980. A wide variety of specimens are issued. These include specimens for: general bacteriology including isolation, sensitivity testing and serology; mycobacterial bacteriology; syphilis serology; virus isolation; general viral serology; rubella serology; hepatitis B antigen detection; electron microscopy; mycology; parasitology; antibiotic assay; public health specimens including milk and water. Laboratories are requested to examine the specimens using their routine procedures and report their results to the Microbiological Quality Control Laboratory (MQCL). The reports are analysed at MQCL and the summarised results of each distribution are sent to all participants. Each participant receives details of his individual performance on current specimens and an analysis of the previous 6 months, cumulative performance. The performance of all laboratories is reviewed twice yearly and laboratories with results significantly worse than those of their peers are offered the opportunity to seek advice and help from a National Advisory Panel of their professional colleagues. The Scheme is confidential and its main role is educational.

Flavobacterium odoratum: a species resistant to a wide range of antimicrobial agents

During the period 1966-77, 24 strains of Flavobacterium odoratum were identified from among strains of Gram-negative, non-fermentative bacteria submitted to the National Collection of Type Cultures for computer-assisted identification. The F. odoratum strains showed resistance to therapeutic levels of gentamicin, tobramycin, amikacin, and carbenicillin as well as to several other antimicrobial agents generally useful in the treatment of infections caused by Gram-negative, non-fermentative bacteria. Two strains isolated from amputation stumps and another three strains isolated in significant numbers from urine specimens were possibly opportunist pathogens. The biochemical characteristics of the 24 strains, the proposed neotype strain of F. odoratum, and three strains representative of a group, referred to at the Center for Disease Control, Atlanta as group M-4f, were compared with those of biochemically similar species which may be isolated from clinical material.

Strains of Achromobacter xylosoxidans from clinical material

Eleven strains of Achromobacter xylosoxidans have been received from among 1106 strains of Gram-negative, non-fermentative bacteria submitted to the National Collection of Type Cultures for computer-assisted identification since 1 January 1972. The strains showed resistance to a wide range of antimicrobial agents and five of the isolates possibly played a pathogenic role. The biochemical characteristics of these 11 strains were compared with those of three culture collection strains.

Isolation of oxidase-positive Gram-negative cocci not belonging to the genus Neisseria from the urogenital tract

In a 12-month period, oxidase-positive, Gram-negative cocci showing similar characteristics in biochemical tests have been isolated from the urogenital tract of 39 male and female patients. Although these organisms superficially resemble Neisseria gonorrhoeae, biochemical characterization and the results of DNA base composition analysis indicate that they do not belong to the genus Neisseria. The relationship of these organisms to the genera Neisseria, Achromobacter, and Pseudomonas is discussed.

Deoxyribonucleic acid reassociation in the classification of flavobacteria

DNA-DNA reassociation studies showed that Flavobacterium emningosepticum strains had a genetic relatedness of 91 to 100% with inter-strain duplexes having high thermal stabilities. The only exception, strain NCTC10016, had an average relatedness of only 43% to other strains of F. meningosepticum. The apparent divergence in DNA base sequence of this strain was reflected in the structural differences of some enzymes. There was a gradation of DNA relatedness among the Flavobacterium group II-b strains, but three strains were sufficiently related to constitute a species. Low levels of genetic relatedness were confirmed between F. meningosepticum and strains of Flavobacterium group II-b, group II-f, F. aquatile, F. breve, F. heparinum, F. pectinovorum, F. odoratum and Moraxella saccharolytica. All strains had base compositions in the range 32 to 46% guanine plus cytosine. The genome sizes of representative strains of F. meningosepticum and Flavobacterium group II-b were 2-50 X 10(9) to 3-52 X 10(9) daltons. The taxonomic implications of these findings are discussed.

Identification and characterization of Moraxella phenylpyruvica

Eight strains of Moraxella phenylpyruvica have been isolated from clinical material in the United Kingdom, the first to be reported from this country. They were characterized, together with three strains of M. phenylpyruvica of the National Collection of Type Cultures (NCTC), and compared with NCTC strains of eight other Moraxella species. The strains of M. phenylpyruvica formed a homogeneous group which is readily distinguishable from other Moraxella species. Deamination of phenylalanine is not restricted to M. phenylpyruvica which, however, is urease positive and is stimulated by bile, in contrast to other Moraxella spp.