Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors.

OBJECTIVES: To review the available literature regarding skills and competencies gained by junior doctors in rural and regional general practice placements and their alignment with the Australian Curriculum Framework for Junior Doctors (ACFJD). STUDY DESIGN: A comprehensive literature review using a three-phase process. Articles were initially identified from database searches in OvidSP and Scopus. Additional information was obtained after a hand search of contents pages from relevant journals and from reports, conference abstracts and grey literature. Documented skills and procedures were mapped against the competencies from the ACFJD. DATA SOURCES: We analysed 36 relevant articles written in English and published during 1997-2011. Articles referring to learning outcomes for junior doctors training with rural general practitioners were included. DATA SYNTHESIS: Evidence was available of the advantages of junior doctor rural general practice placements in gaining advanced skills in the areas of communication and professionalism, as well as developing autonomy in clinical management and decision making. Less evidence was available regarding exposure to particular clinical conditions and development of specific clinical skills. CONCLUSION: Rural and regional general practice placements for junior doctors are likely to comply with the ACFJD requirements and, further, provide excellent learning opportunities in several domains of the curriculum. However, there was little research published confirming learning outcomes for junior doctors in rural general practice settings.

Nitric oxide suppression of cellular proliferation depends on cationic amino acid transporter activity in cytokine-stimulated pulmonary endothelial cells.

Inducible nitric oxide (NO) synthase (iNOS) is a stress response protein upregulated in inflammatory conditions, and NO may suppress cellular proliferation. We hypothesized that preventing L-arginine (L-arg) uptake in endothelial cells would prevent lipopolysaccharide/tumor necrosis factor-α (LPS/TNF)-induced, NO-mediated suppression of cellular proliferation. Bovine pulmonary arterial endothelial cells (bPAEC) were treated with LPS/TNF or vehicle (control), and either 10 mM L-leucine [L-leu; a competitive inhibitor of L-arg uptake by the cationic amino acid transporter (CAT)] or its vehicle. In parallel experiments, iNOS or arginase II were overexpressed in bPAEC using an adenoviral vector (AdiNOS or AdArgII, respectively). LPS/TNF treatment increased the expression of iNOS, arginase II, CAT-1, and CAT-2 mRNA in bPAEC, resulting in greater NO and urea production than in control bPAEC, which was prevented by L-leu. LPS/TNF treatment resulted in fewer viable cells than in controls, and LPS/TNF-stimulated bPAEC treated with L-leu had more viable cells than LPS/TNF treatment alone. LPS/TNF treatment resulted in cleaved caspase-3 and cleaved poly(ADP-ribose) polymerase expression, which was attenuated by L-leu. AdiNOS reduced viable cell number, and treatment of AdiNOS transfected bPAEC with L-leu preserved cell number. AdArgII increased viable cell number, and treatment of AdArgII transfected bPAEC with L-leu prevented the increase in cell number. These data demonstrate that iNOS expression in pulmonary endothelial cells leads to decreased cellular proliferation, which can be attenuated by preventing cellular L-arg uptake. We speculate that CAT activity may represent a novel therapeutic target in inflammatory lung diseases characterized by NO overproduction.

Breath carbon monoxide and semiquantitative saliva cotinine as biomarkers for smoking.

OBJECTIVE: As a biomarker of smoking, semiquantitative analysis of cotinine (NicAlert) offers several advantages over breath carbon monoxide (CO) and quantitative analysis of cotinine. Recent studies have used urine NicAlert and breath CO in combination to verify abstinence. However, no studies have evaluated the performance of saliva NicAlert against or in combination with breath CO. METHOD: Breath CO, saliva NicAlert, and smoking history were compared in an urban population of daily smokers (n = 24) and nonsmokers (n = 25). RESULTS: Saliva NicAlert predicted self-reported smoking with 100% sensitivity and 96% specificity. At a cutoff of > 5 ppm, breath CO had 100% sensitivity and 100% specificity in predicting self-reported smoking. Breath CO was positively correlated with saliva NicAlert and negatively correlated with minutes since last cigarette. CONCLUSION: Saliva NicAlert had high sensitivity and specificity in identifying daily smokers. Compared to saliva NicAlert, breath CO level was more indicative of recent smoking. Future treatment studies should evaluate the performance of saliva NicAlert as an alternative to the urine test.

The one minute mentor: a pilot study assessing medical students' and residents' professional behaviours through recordings of clinical preceptors' immediate feedback.

INTRODUCTION: The assessment of professional development and behaviour is an important issue in the training of medical students and physicians. Several methods have been developed for doing so. What is still needed is a method that combines assessment of actual behaviour in the workplace with timely feedback to learners. GOAL: We describe the development, piloting and evaluation of a method for assessing professional behaviour using digital audio recordings of clinical supervisors' brief feedback. We evaluate the inter-rater reliability, acceptability and feasibility of this approach. METHODS: Six medical students in Year 5 and three GP registrars (residents) took part in this pilot project. Each had a personal digital assistant (PDA) and approached their clinical supervisors to give approximately one minute of verbal feedback on professionalism-related behaviours they had observed in the registrar's clinical encounters. The comments, both in transcribed text format and audio, were scored by five evaluators for competence (the learner's performance) and confidence (how confident the evaluator was that the comment clearly described an observed behaviour or attribute that was relevant). Students and evaluators were surveyed for feedback on the process. RESULTS: Study evaluators rated 29 comments from supervisors in text and audio format. There was good inter-rater reliability (Cronbach alpha around 0.8) on competence scores. There was good agreement (paired t-test) between scores across supervisors for assessments of comments in both written and audio formats. Students found the method helpful in providing feedback on professionalism. Evaluators liked having a relatively objective approach for judging behaviours and attributes but found scoring audio comments to be time-consuming. DISCUSSION: This method of assessing learners' professional behaviour shows potential for providing both formative and summative assessment in a way that is feasible and acceptable to students and evaluators. Initial data shows good reliability but to be valid, training of clinical supervisors is necessary to help them provide useful comments based on defined behaviours and attributes of students. In addition, the validity of the scoring method remains to be confirmed.

Reliability and validity of a short form of the Marijuana Craving Questionnaire.

BACKGROUND: The Marijuana Craving Questionnaire (MCQ) is a valid and reliable, 47-item self-report instrument that assesses marijuana craving along four dimensions: compulsivity, emotionality, expectancy, and purposefulness. For use in research and clinical settings, we constructed a 12-item version of the MCQ by selecting three items from each of the four factors that exhibited the greatest within-factor internal consistency (Cronbach's alpha coefficient). METHODS: Adult marijuana users (n=490), who had made at least one serious attempt to quit marijuana use but were not seeking treatment, completed the MCQ-Short Form (MCQ-SF) in a single session. RESULTS: Confirmatory factor analysis of the MCQ-SF indicated good fit with the 4-factor MCQ model, and the coefficient of congruence indicated moderate similarity in factor patterns and loadings between the MCQ and MCQ-SF. Homogeneity (unidimensionality and internal consistency) of MCQ-SF factors was also consistent with reliability values obtained in the initial validation of the MCQ. CONCLUSIONS: Findings of psychometric fidelity indicate that the MCQ-SF is a reliable and valid measure of the same multidimensional aspects of marijuana craving as the MCQ in marijuana users not seeking treatment.

The determinants of quality in procedural rural medical care.

INTRODUCTION: A substantial proportion of health services for rural Australians is provided in rural health facilities by rurally based generalist health professionals. These services include procedural care within smaller rural hospitals, where teams of health professionals--medical practitioners, nurses and other support staff--work in teams to deliver a range of procedural services, both elective and urgent, that reduce the need for rural people to travel to major centres. Recent debate over the training of rural medical practitioners has focused on whether or not they need to provide procedural services, because current health service management policy appears to support the rationalisation and centralisation of service delivery in larger centres to contain costs and ensure high quality. Hence there is an assumption, without much evidence, that the quality of care in rural hospitals is lower than that provided in larger urban hospitals, although there is little agreement on just what aspects of care should be measured to indicate its quality. This article reports an exploration of multiple perspectives on what constitutes quality of care in rural procedural medical practice, as part of a broader study of the quality of care of a series of real clinical cases. METHODS: During the collection of a series of 91 individual patient cases involving anaesthetic, obstetric or surgical procedures conducted in small rural hospitals, interviews were conducted with several participants in each case: the rural doctors; rural nurses; the rural patients; and family members of those patients. In addition to issues pertaining to each case, interviews explored the perspectives of individuals in each group on the broader question of what constitutes quality of care in a general sense. Their comments were subjected to qualitative thematic analysis using Atlas.ti software (Muhr T, ATLAS.ti Scientific Software Development; Berlin, Germany). In order to consider how to measure rural health care, the thematic comments were then applied to a Donabedian structure/process/outcome model. RESULTS: The different groups produced different views on what might determine the quality of health care in rural hospitals. The health professionals tended to focus on technical aspects of care, although the doctors and nurses had some different emphases, while the patients and their families were more concerned with access, interpersonal communication, convenience and cost. These themes appeared to be consistent with previous literature from general healthcare settings. A list of indicators is suggested for measuring the quality of rural health care. CONCLUSION: This study has improved understanding of the differing views held by rural health professionals and rural patients in thinking about the quality of care provided in rural hospitals. Consideration of the quality of procedural rural medical care should include the needs and expectations of those living and working in a smaller, more familiar environment. This has implications for health planners, and suggests that there is a continuing need for rural health professionals to be trained to provide procedural medical services in rural hospitals, and for rural hospitals to be maintained at a standard necessary to support quality service provision.

The quality of procedural rural medical practice in Australia.

INTRODUCTION: While rural Australians receive much of their procedural medical care from local health professionals in local hospitals, the current workforce shortages, rural economic decline and poor rural health care status all pose challenges to the quality of care they receive. Rural doctors struggle to receive appropriate procedural skills training, rural hospitals struggle to maintain experienced procedurally skilled nurses and other health professionals, and medical equipment, and patients are increasingly referred by clinical protocols to larger urban hospitals. On the other hand, many rural communities value highly their local rural hospital, and advocate the maintenance of hospital services close to home, even though they will have to travel for more specialised services. This article reports an exploration of the quality of a range of clinical cases gathered from rural procedural medical practice. METHODS: The Australian College of Rural and Remote Medicine (ACRRM) approached all trained and procedurally practising rural doctors among their membership. A total of 49 agreed to participate, but only 24 were successful in the prospective recruitment of patients and contribution of patient material (operating theatre notes, anaesthetic records etc) from cases involving general surgery, anaesthetics and obstetrics, the three commonest procedural disciplines in rural medical practice. One of the researchers interviewed patients before and after their procedures and, where available, a family member and a nurse at the hospital. Thus a series of 91 detailed patient case studies was available for analysis These case studies were reviewed from up to four different perspectives: (i) rural doctor peers; (ii) regionalist specialists in the respective discipline; (iii) a medical administrator; and (iv) a rural consumer representative. A thematic analysis of transcribed interviews was conducted. RESULTS: The collected cases represented a range of procedures commonly provided in rural hospitals, although there were relatively few surgical procedures and there was a bias in all three specialty areas towards relatively simple procedures. No adverse outcomes were reported, although some comments, particularly from the rural doctor peers, were made about the need for further information and, in a small number of cases, possible variance from accepted practice. The views of the reviewers substantially agreed that the cases were of average to high quality, although the specialist reviewers were less likely to rate care as 'excellent' than other reviewers. While the comments of the medical reviewers were more technical in nature, the comments of patients and their families, and of the rural consumer reviewer, focussed more on issues such as accessibility, cost and interpersonal communication. Many patients and some nursing staff expressed concern about the sustainability of friendly and accessible local services in the face of workforce shortages and pressure to downgrade rural hospitals. CONCLUSION: This study shows that, where staff and facilities in rural hospitals are accredited for procedural care, there is little evidence of any difference in the quality of that care provided when compared with care expected in urban hospitals.

A P53-dependent, telomere-independent proliferative life span barrier in human astrocytes consistent with the molecular genetics of glioma development.

An in vitro model, based on normal (primary) human astrocytes (NHAs), was used to investigate the nature of the selection pressures for events that occur during the progression of astrocyte-derived tumors and, in particular, the potential role of proliferative life span barriers (PLBs). As with fibroblasts, NHAs senesced with elevated p21(WAF1) and senescence-associated beta-galactosidase activities. Unlike fibroblasts, replicative senescence (M1) occurred much earlier, after approximately 20 pd and was not bypassed by hTERT expression. Abrogation of p53 function, by expression of human papillomavirus type 16 E6, led to an extension of life span, implying that replicative senescence in NHAs was p53-dependent but telomere-independent. human papillomavirus type16 E6 expression promoted additional growth of up to 12 pd, until a second telomere-independent PLB (termed M(INT)) was imposed associated with elevated p16(INK4A) levels. A proportion of cells escaped from M(INT) lost p16(INK4A) expression and achieved approximately an additional 25 pd until a crisis-like third PLB (M2) was reached. Expression of hTERT in post-M(INT) cells allowed these cells to become immortal and bypass this third PLB. The in vitro PLBs appear, in order of occurrence, dependent upon p53, p16(INK4A), and telomere erosion, a situation that mirrors an equivalent order of mutational events during tumor progression in vivo. This study describes a model that provides a plausible explanation for the selective pressures driving mutational events in this tumor type and provides direct evidence of a p53-dependent, telomere-independent PLB.