Specialist training

Specialist training must be reshaped to meet the challenges of new systems for the delivery of health care and rapid expansion in biomedical knowledge. An adequate and affordable supply of trained specialists and generalists able to deal with the health problems of populations served, is the responsibility of governments and policymakers that fund and those who deliver graduate education. Clearly defined objectives for specialist training are needed, linked to planning for the medical workforce size. A balance between numbers of specialists and generalists is essential, although flexibility in programmes should allow individuals to change. Curricula for all specialties should be published. Strategies and methods for delivery of graduate education and training must be coherent with those of medical schools. Training should be planned and sequenced to meet the identified needs of individuals. Those who teach should themselves learn how to train and assess trainees. The location for training should reflect present and future clinical practice if disfunction between medical education and the health of populations served and their need is to be avoided. Specialist training should form the basis for continuing education by encouraging lifelong, evidence-based learning. Any reshaping of specialist training must be consistent with the continuum of medical education. Instruments for assessment of specialists in training have to be refined, based on action research. Ensuring mastery in the competencies of each component of the curriculum is essential. Those competencies will change in consequence of altered societal needs plus advances in technology and biomedical knowledge.     

Pathways of lymph flow through intestinal lymph nodes in the horse

In the horse, several thousand lymph nodes receive lymph from the intestine, part of which is very large and contains microorganisms that enable the animal to utilize refractory dietary constituents such as cellulose. The aim of this study was to describe the pathways by which lymph is delivered into, traverses, and is drained from these lymph nodes. These pathways were studied with either Microfil or methacrylate casting materials and with light and electron microscopy. The afferent lymphatic vessel delivering lymph into one of the nodes divides over the capsular surface and within trabeculae into terminal branches, and these are continuous with the subcapsular and trabecular sinuses through rounded holes up to 30 μm across. Lymph is conveyed from the subcapsular and trabecular sinuses through the cortex by four types of sinuses: trabecular sinuses, cortical tubular sinuses, tubulelike sinuses with a network of stellate cell processes, and sinuses between cortical cords. It is conveyed through the medulla by sinuses both within and between medullary cords. Lymph is drained from these sinuses by initial efferent lymphatics of three types: those between medullary cords, those within the subcapsular sinus overlying medullary or cortical cords, and those within trabeculae. All three types are continuous with surrounding sinuses through holes 5–30 μm across. These three alternative routes for lymph drainage may ensure adequate lymph flow during different intranodal conditions that may exist when the node is responding to microcrganisms or other foreign materials.     

Comparison of ultrasonic cleaning schemes: a pilot study.

OBJECTIVE: Ultrasonic cleaning is an effective method for cleaning dental instruments prior to sterilisation. However, there are few studies that directly compare precleaning and ultrasonic cleaning solutions. This study evaluated the efficacy of different ultrasonic cleaning schemes. METHOD AND MATERIALS: Twenty representative dental instruments, five of which were soiled with a mixture of blood and hydroxyapatite, were used in a series of cleaning runs. Cleaning employed a presoaking agent, ultrasonic cleaning, or a combination of both. Two presoaking agents (Non-ionic Ultrasonic Cleaning Solution and ProEZ Foaming Enzymatic Spray) plus five ultrasonic cleaners (UltraDose, General Purpose Cleaner, Co-enzyme Concentrate, Enzol Enzymatic Detergent, and Non-ionic Ultrasonic Cleaning Solution) were compared, with tap water serving as a control. There were two cleaning times: seven and 15 minutes. After rinsing, the working ends of the instruments underwent scrubbing for 20 seconds using a dental polishing brush held in a haemostat. After scrubbing, the brush and instrument were placed in a tube containing sterile saline. Vortexing of the tube lasted 30 seconds. Testing for the post-cleaning presence of blood involved Hemastix dipsticks. These sticks measure minute amounts of blood in urine and can detect as few as 35 red blood cells per ml. Comparisons of colour change were made to a standard scale followed by assignment of numeric values. RESULTS: Tap water was the poorest cleaning solution, while UltraDose was the most effective. Blood removal improved when cleaning time was increased from seven to 15 minutes. The combined effect of a presoak immersion followed by ultrasonic cleaning was the most effective cleaning scheme overall. Cleaning by either ultrasound or presoaking only was less effective. Some instruments were more difficult to clean than others. CONCLUSION: Within the constraints of the small number of test runs performed, it was concluded that application of a presoak agent before ultrasonic cleaning produced the most effective instrument-cleaning regimen.     

Leukaemia Inhibitory Factor or Related Factors Promote the Differentiation of Neuronal and Astrocytic Precursors within the Developing Murine Spinal Cord

Previously we have shown that leukaemia inhibitory factor (LIF) potentiates the development of murine spinal cord neurons in vitro , suggesting that it, or related factors, may play an important regulatory role in neuronal development. We have further investigated this role and show here that the generation of neurons in cultures of embryonic day 10 spinal cord cells is inhibited by antibodies to the β subunit of the LIF receptor. Since there are more undifferentiated precursors in antibody-treated cultures than in control and LIF-treated cultures, it is concluded that the primary action of LIF, or related molecules, is to promote neuronal differentiation, not precursor survival. In addition, the failure of LIF to support neuronal survival in the period immediately following differentiation suggests that the increased numbers of neurons generated with LIF are not attributable to its neurotrophic action. By selecting neuronal precursors on the basis of their inability to express class I major histocompatibility complex molecules, it was shown that LIF acted directly upon these cells and not via an intermediary cell. LIF also appears to be involved in regulating the differentiation of astrocytes, since it increases the number of glial fibrillary protein (GFAP)-positive cells present in the cultures and since the spontaneous production of GFAP-positive cells is blocked by antibodies to the LIF β receptor. These findings suggest that LIF or related factors promote the differentiation of neural precursors in the spinal cord, but that they are not involved in preferentially promoting precursors down a specific differentiation pathway.     

Validity of a hinged constant force probe and a similar, immobilised probe in untreated periodontal disease

The validity of a hinged constant force probe (0.25 N) was compared with that of a similar but immobilised instrument, using the same interchangeable tip for both (0.64 mm diameter; 2 mm divisions). 60 sites were measured on teeth which were extracted subsequently, in patients with untreated periodontal disease, and the connective tissue attachment level was used as validity criterion. The clinical measurements of both probes correlated well with each other, but they differed significantly from the post-extraction connective tissue attachment level measurements, indicating a point 1.2 mm coronally to this, on average. A companion investigation of intra-operator probing depth reproducibility with the 2 probes, was undertaken in 14 patients, at 2 visits separated by 1 week in each case. All patients had untreated periodontal disease. A difference between probes was found at the first visit, but not at the second; the immobilised probe showed a difference between visits, reducing mean probing depth slightly at the second; when the immobilised probe was used first, there was a difference between probes. Further analysis of the results indicated that there was greatest agreement between probes when the constant force probe had been used before the immobilised probe at the second visit. The results suggested that these probes indicated a point above the connective tissue attachment level, related to pocket morphology, and that there was a moderate learning effect due to operator use of the constant force probe, which modified use of the immobilised probe.     

MANAGEMENT OF SEMINOMA OF THE TESTIS: RECOMMENDATIONS BASED ON TREATMENT RESULTS

Background : The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine ‘best practice’ management protocols based on our results and a review of the relevant literature. Methods : (i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department. Results : Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5–10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10cm). the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment. Conclusions : Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IA and IIB (5–10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.