Learning curves are often referred to in the context of medical education and training, though their trajectories and natures are a matter of debate. The origins of this concept derive from industry and its relevance to contemporary medicine and surgery remains controversial. We describe the history, derivation, character and possible mechanisms to deal with the implications of learning curves in the current climate of clinical governance and modernising medical careers.

Summary:A patient is described with severe haemorrhage from a lumbar artery foflowing percutaneous renal biopsy. The exact source of haemorrhage in this previously unreported complication proved difficult to locate even at surgical exploration.

Our data demonstrate the development of tolerance and early attenuation of effect on left ventricular filling pressure with frequent oral dosing (Q 4 and Q 6 hours) with ISDN in patients with chronic CHF, which may be related to persistently elevated trough blood levels of ISDN. The development of tolerance can be reversed after a washout period of 12 hours and can be prevented with a Q 8-hour administration. These regimens, however, are limited by an inconsistent effect. Although long-term implications of these findings need further evaluation, the present study demonstrates the difficulty of maintaining a persistent ISDN-mediated reduction in left ventricular filling pressure in patients with chronic, moderate to severe CHF. These results suggest the need to use intermittent ISDN therapy allowing a daily nitrate washout interval and the rationale for combined vasodilator therapy in patients with CHF.

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