Monitoring standards of training.

In postgraduate medical education there will always be a tension between delivering the service and ensuring time for reflection and learning. The balance requires monitoring to ensure national implementation of standards and to provide an external review for hospitals. However, the current system in the United Kingdom of visiting by many different agencies is disruptive to hospitals and wasteful of resources. The North Western Deanery has worked with medical royal colleges to develop a co-ordinated system of visiting and reporting which is designed to share information and expertise while reducing the pressure on hospitals. SETTING AND MAINTAINING STANDARDS: Clear standards are published and hospitals are encouraged to measure their own performance against these so that they are able to address identified problems. The effectiveness of the visits depends on collection and collation of data, especially face-to-face interviews with trainees and consultants. At the end of the visit a structured verbal feedback is given to senior managers and clinicians in the hospital and is followed by a written report. IMPROVING THE QUALITY OF TRAINING: Systematic review of training placements by the postgraduate dean's team has resulted in a steady increase in the quality of training placements and a structured approach has given trusts a framework to review the quality of training between visits. The future must lie in greater investment of responsibility in postgraduate deans for routine monitoring of training placements to consistent standards, which would allow the newly emerging Medical Education Standards Board (MESB) to review deaneries rather than individual placements.

Distribution of activated neurons in the rabbit brain following a volume load.

Immunohistochemical detection of the protein, Fos, was used to identify neurons in the brain activated following a volume load. The plasma expanders, Haemaccel and 6% dextran, were infused intravenously in conscious rabbits for 60 min. Compared to control animals both stimuli significantly increased right atrial pressure but had no effect on blood pressure. Heart rate was significantly elevated with dextran only. Volume expansion with Haemaccel also reduced renal sympathetic nerve activity by about 50% from the pre-infusion resting level. Ninety minutes after the start of the infusion, the rabbits were perfusion fixed and the distribution of Fos-positive cell nuclei was examined. Following Haemaccel infusion there were significant increases in the number of Fos-positive cell nuclei in the organum vasculosum of the lamina terminalis, parvocellular paraventricular nucleus and in specific rostrocaudal levels of the nucleus tractus solitarius and ventrolateral medulla. Following dextran similar effects were observed in the medulla but Fos-positive cell nuclei were not significantly elevated above controls in the forebrain. After Haemaccel or dextran areas such as the supraoptic nucleus, the magnocellular paraventricular nucleus, the bed nucleus of the stria terminalis, diagonal band of Broca and amygdala either did not produce Fos or were not consistently different from the control group. The results suggest that specific brain regions, that are known to be important in cardiovascular control, are activated by a volume load. These areas are likely to play an important role in the reflex responses initiated by that particular stimulus.

Effect of intravenous angiotensin II on Fos distribution and drinking behavior in rabbits.

We investigated the effect of intravenous infusion of angiotensin II (ANG II, 40 ng.kg-1.min-1) on the distribution of Fos in the subfornical organ (SFO), organum vasculosum of the lamina terminalis (OVLT), and the medulla of the conscious rabbit. ANG II elicited significant increases in the number of Fos-positive cell nuclei in the SFO and OVLT (15- and 10-fold, respectively). Raising blood pressure with phenylephrine did not elicit Fos in these nuclei. These nuclei are believed to be responsible for the dipsogenic actions of ANG II; however, ANG II was not dipsogenic. When blood pressure was held at preinfusion levels by the coadministration of sodium nitroprus-side and ANG II, the rabbits did not drink but Fos production in the lamina terminalis was elevated. In the medulla, ANG II did not significantly increase Fos production in the nucleus of the solitary tract (NTS) or ventrolateral medulla (VLM). However, with the coadministration of sodium nitroprusside, there were marked increases in the NTS and VLM. The results suggest that neurons in the SFO and OVLT are either not involved in the dipsogenic pathways or there is disruption further downstream in the central pathways that would normally mediate a drinking response to ANG II.

Managing the practice team.

Practices do not manage themselves; they need the type of leadership the GP is best placed to supply. Skills we develop in the clinical setting can be combined with practice audit to produce the ideal management stratagem.