Adaptation and initial examination of the psychometric properties of the Short Supervisory Relationship Questionnaire (SSRQ) for use with general practice registrars.

The relationship between general practice (GP) registrars and their supervisors underpins the training experience for the next generation of medical practitioners. Building on recent research into the development and validation of a measure of the relationship between registrars and supervisors from the perspective of the supervisor, the current study focuses on the educational alliance from the perspective of the registrar. This paper presents an adaptation and initial validation of the clinical psychology supervisory relationship measure for GP registrars in an Australian context. Following an Expert Group review and adaptation of the items, 238 GP registrars completed the adapted tool. Using exploratory factor analysis and Procrustes confirmatory rotation, an optimal four factor model of the supervisory relationship was identified, reflecting measures of Safe base (α =.93), Supervisor investment (α =.96), Registrar professionalism (α =.90), and Emotional intelligence (α =.87). The general practice supervisory relationship measure for registrars (GP-SRMR) demonstrated excellent model fit, high internal consistency, and was theoretically consistent with the original tool. Implications for clinical education and future research are presented.

Adapting the supervisory relationship measure for general medical practice.

BACKGROUND: The relationship between general practice (GP) supervisors and registrars is a critical component in effective training for the next generation of medical practitioners. Despite the importance of the relational aspect of clinical education, most evaluation has traditionally occurred from the perspective of the registrar only. As such, no validated tools exist to measure the quality of the supervisory relationship from the perspective of the supervisor. This paper presents an adaptation and validation of the clinical psychology supervisory relationship measure (Pearce et al, Br J Clin Psychol 52:249-68, 2013) for GP supervisors in an Australian context. METHOD: Following an Expert Group review and adaptation of the items, 338 GP supervisors completed the adapted tool. RESULTS: Using principal components analysis and Procrustes confirmatory rotation, an optimal three-component model of supervisory relationship was identified, reflecting measures of Safe base (α = .96), Supervisor investment (α = .85), and Registrar professionalism (α = .94). CONCLUSIONS: The general practice supervisory relationship measure (GP-SRM) demonstrated excellent model fit, high internal consistency, and was theoretically consistent with the original tool. Implications for clinical education and future research are presented.

Do multidisciplinary care plans result in better care for patients with type 2 diabetes?

BACKGROUND: Since the introduction of the Enhanced Primary Care package, care plans have become part of Australian general practice. Previous research has focused on barriers to the uptake of care plans. This study examined the effect of multidisciplinary care plans on provision and outcome of care for patients with type 2 diabetes. METHODS: A retrospective before/after medical record audit design was chosen. Subjects of the study were general practitioners practising in Southwest Sydney (New South Wales) and their diabetic patients who had written care plans. Outcome measures were frequency and results of glycosylated haemoglobin, blood pressure, foot, serum lipids, weight, and microalbumin checks. RESULTS: The medical records of 230 patients were audited. Following the care plan, adherence to diabetes guidelines increased. Metabolic control and cardiovascular risk factors improved for patients who had multidisciplinary care implemented. DISCUSSION: Whether the improved diabetes care shown here is attributed to improved teamwork and/or coordination of care needs further research.

Region-specific increases in FosB/ΔFosB immunoreactivity in the rat brain in response to chronic sleep restriction.

Using a rat model of chronic sleep restriction (CSR) featuring periodic sleep deprivation with slowly rotating wheels (3h on/1h off), we previously observed that 99h of this protocol induced both homeostatic and allostatic (adaptive) changes in physiological and behavioural measures. Notably, the initial changes in sleep intensity and attention performance gradually adapted during CSR despite accumulating sleep loss. To identify brain regions involved in these responses, we used FosB/ΔFosB immunohistochemistry as a marker of chronic neuronal activation. Adult male rats were housed in motorized activity wheels and underwent the 3/1 CSR protocol for 99h, or 99h followed by 6 or 12days of recovery. Control rats were housed in home cages, locked activity wheels, or unlocked activity wheels that the animals could turn freely. Immunohistochemistry was conducted using an antibody that recognized both FosB and ΔFosB, and 24 brain regions involved in sleep/wake, autonomic, and limbic functions were examined. The number of darkly-stained FosB/ΔFosB-immunoreactive cells was increased immediately following 99h of CSR in 8/24 brain regions, including the medial preoptic and perifornical lateral hypothalamic areas, dorsomedial and paraventricular hypothalamic nuclei, and paraventricular thalamic nucleus. FosB/ΔFosB labeling was at control levels in all 8 brain areas following 6 or 12 recovery days, suggesting that most of the immunoreactivity immediately after CSR reflected FosB, the more transient marker of chronic neuronal activation. This region-specific induction of FosB/ΔFosB following CSR may be involved in the mechanisms underlying the allostatic changes in behavioural and physiological responses to CSR.

Differential c-Fos immunoreactivity in arousal-promoting cell groups following systemic administration of caffeine in rats.

Despite the widespread use of caffeine, the neuronal mechanisms underlying its stimulatory effects are not completely understood. By using c-Fos immunohistochemistry as a marker of neuronal activation, we recently showed that stimulant doses of caffeine activate arousal-promoting hypothalamic orexin (hypocretin) neurons. In the present study, we investigated whether other key neurons of the arousal system are also activated by caffeine, via dual immunostaining for c-Fos and transmitter markers. Rats were administered three doses of caffeine or saline vehicle during the light phase. Caffeine at 10 and 30 mg/kg, i.p., increased motor activities, including locomotion, compared with after saline or a higher dose, 75 mg/kg. The three doses of caffeine induced distinct dose-related patterns of c-Fos immunoreactivity in several arousal-promoting areas, including orexin neurons and adjacent neurons containing neither orexin nor melanin-concentrating hormone; tuberomammillary histaminergic neurons; locus coeruleus noradrenergic neurons; noncholinergic basal forebrain neurons that do not contain parvalbumin; and nondopaminergic neurons in the ventral tegmental area. At any dose used, caffeine induced little or no c-Fos expression in cholinergic neurons of the basal forebrain and mesopontine tegmentum; dopaminergic neurons of the ventral tegmental area, central gray, and substantia nigra pars compacta; and serotonergic neurons in the dorsal raphe nucleus. Saline controls exhibited only few c-Fos-positive cells in most of the cell groups examined. These results indicate that motor-stimulatory doses of caffeine induce a remarkably restricted pattern of c-Fos expression in the arousal-promoting system and suggest that this specific neuronal activation may be involved in the behavioral arousal by caffeine.

GP claims for completing diabetes 'cycle of care'.

BACKGROUND: There is a wide variability in the level of claims for diabetes. Service Incentive Payments (SIP) by general practitioners. METHOD: Cross sectional comparison of the ratio of the number of SIP items claimed between August 2002 and July 2003 to the estimated prevalence of diabetes by divisions of general practice (DGP). PARTICIPANTS AND SETTING: Seventy-nine of the 101 DGP with diabetes programs in 2002. RESULTS: The average ratio of diabetes SIP claims to estimated diabetes prevalence (including both diagnosed and undiagnosed cases) for each quarter of the year between August 2002 and July 2003 was 10.1% (standard deviation 3.6). This ratio was higher in DGP with a more disadvantaged population, and more of their GP members in large practices. The provision of IT support in DGP and the proportion of GPs who had patients registered on the division's register were associated with a higher ratio of claims. A multiple regression model with two factors: socioeconomic disadvantage and the proportion of GP members in practices of five or more GPs predicted 41% of the variance. CONCLUSION: Divisions of general practice appear to be supporting practices serving disadvantaged populations to deliver quality care for patients with chronic disease. The association with practice size and DGP activities suggests that practice organisation and systems are important in the provision of good care for patients with chronic disease.

Social and environmental contexts modulate sleep deprivation-induced c-Fos activation in rats.

People often sleep deprive themselves voluntarily for social and lifestyle reasons. Animals also appear to stay awake longer as a result of their natural curiosity to explore novel environments and interact socially with conspecifics. Although multiple arousal systems in the brain are known to act jointly to promote and maintain wakefulness, it remains unclear whether these systems are similarly engaged during voluntary vs. forced wakefulness. Using c-Fos immunohistochemistry, we compared neuronal responses in rats deprived of sleep for 2 h by gentle sensory stimulation, exploration under social isolation, or exploration with social interaction, and rats under undisturbed control conditions. In many arousal, limbic, and autonomic nuclei examined (e.g., anterior cingulate cortex and locus coeruleus), the two sleep deprivation procedures involving exploration were similarly effective, and both were more effective than sleep deprivation with sensory stimulation, in increasing the number of c-Fos immunoreactive neurons. However, some nuclei (e.g., paraventricular hypothalamic nucleus and select amygdala nuclei) were more responsive to exploration with social interaction, while others (e.g., histaminergic tuberomammillary nucleus) responded more strongly to exploration in social isolation. In the rostral basal forebrain, cholinergic and GABAergic neurons responded preferentially to exploration with social interaction, whereas resident neurons in general responded most strongly to exploration without social interaction. These results indicate that voluntary exploration with/without social interaction is more effective than forced sleep deprivation with gentle sensory stimulation for inducing c-Fos in arousal and limbic/autonomic brain regions, and suggest that these nuclei participate in different aspects of arousal during sustained voluntary wakefulness.

Cardiovascular risk levels in general practice patients with type 2 diabetes in rural and urban areas.

OBJECTIVE: To investigate the change of cardiovascular risk factor from 2000 to 2002 in general practice patients with type 2 diabetes in urban and rural areas, and the association between cardiovascular risk (both single risk factors and coronary heart disease absolute risk (CHDAR)) and rurality in three years. METHODS: In total, 6305 patients were extracted from 16 Divisions (250 practices). Multivariate regression at Division, practice and patient levels was conducted with adjustment for age and gender. RESULTS: In each of the three years, most single individual risk factors and CHDAR were high. Comparing 2002 with 2000: for urban patients in 2002 total cholesterol (OR 0.85) and low-density lipoprotein (OR 0.81) significantly decreased, and high-density lipoprotein (HDL) (OR 1.16) significantly increased; for rural patients in 2002 HbA1c (OR 0.85) significantly decreased and HDL (OR 1.22) significantly increased; and CHDAR significantly improved only in urban patients (OR 0.93) in 2002. In 2002 rural patients were still more likely to be overweight/obese (OR 1.16), be current smokers (OR 1.36), and have worse HDL (OR 0.84) and triglycerides (OR 1.23) than their urban counterparts. CONCLUSION: Some key individual risk factors and CHDAR did not improve in rural patients with type 2 diabetes despite a number of programs designed to provide comprehensive care to rural patients with diabetes. More emphasis is needed on supporting access to lifestyle changes (such as smoking, diet and physical activity) in rural primary health care.

Indirect projections from the suprachiasmatic nucleus to the ventrolateral preoptic nucleus: a dual tract-tracing study in rat.

The suprachiasmatic nucleus (SCN) contains a master clock for most circadian rhythms in mammals, including daily sleep-wake cycles. The ventrolateral preoptic nucleus (VLPO) plays a key role in sleep generation and, as such, might be an important target of the SCN circadian signal. However, direct SCN projections to the VLPO are limited, suggesting that most of the SCN output to the VLPO might be conveyed indirectly. We examined this possibility by microinjecting selected known major targets of SCN efferents with biotinylated dextran-amine and/or cholera toxin B subunit, followed by analyses of retrograde labelling in the SCN and anterograde labelling in the VLPO. Retrograde labelling results confirmed that the medial preoptic area, subparaventricular zone, dorsomedial hypothalamic nucleus and posterior hypothalamic area all received projections from the SCN; these projections arose predominantly from the shell, as opposed to the core, of the SCN. Anterograde labelling results indicated that these same nuclei also projected to the VLPO, mainly its medial and ventral aspects. Comparison of the results of injections of similar sizes across different target groups indicated that the rostral part of the medial preoptic area and the caudal part of the dorsomedial hypothalamic nucleus were particularly noteworthy for the abundance of both SCN source neurons and efferent fibres and terminals in the VLPO. These results suggest that the SCN might provide indirect input to the VLPO via the medial preoptic area and the dorsomedial hypothalamic nucleus, and that these indirect neuronal pathways might play a major role in circadian control of sleep-wake cycles.

Substance P in the descending cholinergic projection to REM sleep-induction regions of the rat pontine reticular formation: anatomical and electrophysiological analyses.

Release of acetylcholine within the pontine reticular formation (PRF) from the axon terminals of mesopontine cholinergic neurons has long been hypothesized to play an important role in rapid eye movement (REM) sleep generation. As some of these cholinergic neurons are known to contain substance P (SP), we used anatomical, electrophysiological and pharmacological techniques to characterize this projection in the rat. Double immunofluorescence demonstrated that 16% of all cholinergic neurons within the mesopontine tegmentum contained SP; this percentage increased to 27% in its caudal regions. When double immunofluorescence was combined with retrograde tracing techniques, it was observed that up to 11% of all SP-containing cholinergic neurons project to the PRF. Whole-cell patch-clamp recordings from in vitro brainstem slices revealed that SP administration depolarized or evoked an inward current in a dose-dependent manner in all PRF neurons examined, and that these effects were antagonized by a SP antagonist. The amplitude of the SP-induced inward current varied with changes in the Na+ concentration, did not reverse at the calculated K+ or Cl- equilibrium potentials, and was not attenuated in the presence of tetrodotoxin, low Ca2+ concentration or caesium ions. These data suggest that activation of a tetrodotoxin-insensitive cation channel(s) permeable to Na+ is responsible for a SP-induced inward current at resting membrane potentials. The depolarizing actions of SP appeared to be primarily due to activation of the adenylate cyclase pathway, and were additive with cholinergic receptor activation even at maximal concentrations. These data indicate that SP is colocalized in a subpopulation of mesopontine tegmental cholinergic neurons projecting to REM sleep-induction regions of the PRF, and that actions of these two neuroactive substances on PRF neurons are additive. If SP is coreleased with acetylcholine, the additive actions of the two neurotransmitters might heighten the excitability of postsynaptic PRF neurons and ensure the initiation and maintenance of REM sleep.

Register-Recall Systems: Tools for Chronic Disease Management in General Practice.

The Divisions Diabetes and Cardiovascular Disease Quality Improvement Project (DDCQIP) is a national project that aims to promote quality improvement initiatives among Divisions of General Practice. DDCQIP has investigated the growth of Division-based diabetes and cardiovascular disease register-recall systems and the role they play in promoting evidence-based structured care within general practice. In the period 2000-2002, an increase in the number of GPs using register-recall systems and the rise in the number of active registered patients have made it possible to monitor quality of care and health outcome indicators, and contributed to the growth of a Division-based population health program.