By O. Onatas. Palm Beach Atlantic College.

This programme will adopt progression criteria in accordance with the University’s regulation should they change (we understand that these are being reviewed currently and are awaiting formalisation) purchase 0.5 mg prandin with mastercard. The 20-credit Science of Medicine course will have double the weighting to the other 10-credit modules purchase 0.5 mg prandin visa. Taking this into account, the assignment marks in each year will aggregated by averaging. Sufficiently high marks must be achieved at the first sitting in the first year (certificate) to allow progression to the second year (diploma) (see above). The diploma will be marked by two Internal Examiners with quality assurance and check-marking by the External Examiner. The provisional marks and marker comments will be discussed by the Board of Examiners and a decision taken as to the mark awarded and feedback to be given to the candidate. Only one submission of a dissertation (or any of the other assignments) is permitted. Note that major correction and resubmission is not permitted under University regulations (see below). Students achieving at least 70% (Grade A) for the dissertation and an average close to 70% for the rest of the assignments will be awarded ‘master’s with distinction’. For those electing to leave the programme after two years with a diploma, an average assignment mark of 70% or more will earn the award of ‘diploma with distinction’. Late work or extensions for study Submission dates You will be given submission dates for coursework at the start of each module. Consideration of late work lies with the Board of Postgraduate Studies and not with the Programme Directors. Normally a penalty of 5% loss of points will be imposed per day of late submission up to the end of the fifth day. Work that is late for some other reason, (“run out of time”, for example) must be accompanied by a letter of explanation of circumstances, and will be considered by the Board of Examiners (BoE). Students suffering from illness during any assessment should obtain a medical certificate from their doctor as soon as possible and report the situation to the course organiser, who should bring evidence of illness or other mitigating circumstances to the attention of the board of examiners. Interruptions of study An interruption of study concession is applicable where a student is unable to work on the thesis for a significant period of time due to circumstances that are largely beyond their own control. Periods of interruption do not count towards the student’s total permitted period of study and do not incur any additional fees or charges. Students should be encouraged to request an IoS as soon as it is apparent that it is justified, rather than waiting to submit a retrospective one at a later date. At the University of Edinburgh, the academic body would normally be the Board of Examiners. Any student wishing to submit an appeal must have legitimate grounds for doing so, namely one or both of the following: (a) Substantial information directly relevant to the quality of performance in the examination which for good reason was not available to the examiners when their decision was taken. For this purpose “conduct of an examination” includes conduct of a meeting of the Board of Examiners. An appeal cannot be lodged until the decision being appealed has been ratified by the appropriate Board of Examiners. There are strict timescales for the submission of academic appeals: Final Year Student / Graduate Continuing Student 6 weeks after results issued 2 weeks after results issued Late appeals may be considered where there are special circumstances in relation to the late submission of the appeal. A subcommittee of the Appeal Committee can consider whether late appeals are allowed to progress. Plagiarism is a serious disciplinary offence and even unintentional plagiarism can be a disciplinary matter. The University of Edinburgh has always taken a strong stand against plagiarism and cheating, and penalties are severe. The University considers the following documents to be essential reading for all students prior to embarking on their studies, and for both staff and students. Student will be expected to be familiar with these regulations in the event of an appeal. Many of the regulations and issues are already covered elsewhere in this handbook, such as the University’s ‘common marking scheme’, but we have highlighted a few pertinent aspects for your attention below. Postgraduate assessment regulations General University-wide regulations relating to all aspects of assessment are available at www. Please use your unique examination number from your matriculation card for assignments, rather than your name or matriculation number. Code of practice for taught postgraduate programmes This in no way supersedes the above University regulations, but acts as a guide to required practice based upon the University’s regulations and reasonable expectations. Their purpose is to enable students to make the most of their programme and to avoid or overcome difficulties. Students should be made aware that approval by a supervisor, and the following of the advice and guidance of the supervisor carries no guarantee of success at examination (of the dissertation). Progress to the dissertation component is conditional on a good performance in continuous assessment and examinations at the first attempt. Any appeal must be submitted in writing to the University Secretary as soon as possible (usually less than 6 weeks). Representation and informal feedback from any student is welcome by this group at any time. Appendix I: It is the duty of all students to observe those parts of the University Health and Safety Policy relevant to their own work: see www. Please note: This programme handbook in no way supersedes University regulations, but seeks to interpret and apply these and to provide further information relating to this particular programme. Those entering Year 3 (dissertation) of the programme will also be expected to follow the University’s Code of Good Practice in Research, available from www. The Curriculum and Assessment Committee are responsible for all decisions about programme outcomes, content, assessment and evaluation, and make recommendations for the constitution of the Board of Examiners and appointment of External Examiners. Student feedback and course evaluation Student feedback provides invaluable input to the review and development of curriculum and course organisation. At the beginning of the session students will be asked to elect programme representatives, the representatives can raise issues of general concern on behalf of their class. However all students should feel free to approach staff at any time throughout a session.

If not purchase 0.5 mg prandin visa, either do not do the test generic prandin 1 mg on-line, or be prepared to do a second or even a third test to confirm the diagnosis. Next, is the patient interested in having the test done and are they going to be “part of the team? Give the information to the patient in a manner they can understand and then ask them if they want to go through with the testing. They ought to understand the risks of disease, and of correct and incorrect results of testing, and the ramifications of a positive and negative test results. The decision making for this problem is very complex and should be done through careful consideration of all of the options and the patients’ situation such as age, general health, and the presence of other medical conditions. Finally, how will a positive or negative result help the patient reach his or her goals for treatment? If the patient has “heartburn” and you no longer sus- pect a cardiac problem, but suspect gastritis or peptic ulcers, will doing a test for Helicobacter pylori infection as a cause of ulcers and treatment with specific anti-microbial drugs if positive, or symptomatic treatment if negative, satisfy the patient that he or she does not have a gastric carcinoma? If not, then endoscopy, Sources of bias and critical appraisal of studies of diagnostic tests 309 the gold standard in this case, ought to be considered without stopping for the intermediate test. Studies of diagnostic tests should determine the sensitivity and specificity of the test under varying circumstances. The prevalence of disease in the popula- tion studied may be very different from that in most clinical practices. There- fore, predictive values reported in the literature should be reserved for validation studies and studies of the use of the test under well-defined clinical conditions. Remember that the predictive value of a test is dependent not only on the likeli- hood ratios, but also very directly on the pretest probability of disease. Final thoughts about diagnostic test studies It is critical to realize that studies of diagnostic tests done in the past were often done using different methodology than what is now recommended. Many of the studies done years ago only looked for the correlation between a diagnostic test and the final diagnosis. For example, a study of pneumonia might look at all physical examination findings for patients who were subjected to chest x-rays, and determine which correlated most closely with a positive chest x-ray, the gold standard. First, the patients are selected by inclusion criteria that include getting the test done, here a chest x-ray, which already narrows down the probability that they have the illness. Second, correlation only tells us that you are more or less likely to find a certain clinical finding with an illness. It does not tell you what the probability of the illness is after applica- tion of that finding or test. The correlation does not give the same useful infor- mation that you get from likelihood ratios or sensitivity and specificity. Those will tell the clinician how certain diagnostic findings correlate with the presence of illness and how to use those clinical findings to determine the presence or absence of disease. You have attempted to tinge it with romanticism, which produces much the same effect as if you worked a love-story or an elopement into the fifth proposition of Euclid. Sir Arthur Conan Doyle (1859–1930): The Sign of Four, 1890 Learning objectives In this chapter you will learn: r the attributes of a good screening test r the effects of lead-time and length-time biases and how to recognize them in evaluating a screening test r how to evaluate the usefulness of a screening test r how to evaluate studies of screening tests Introduction Screening tests are defined as diagnostic tests that are useful in detecting disease in asymptomatic or presymptomatic persons. The goal of all screening tests is to diagnose the disease at a stage when it is more easily curable (Fig. This is usually earlier than the symptomatic stage and is one of the reasons for doing a diagnostic test to screen for disease. Screening tests must rise to a higher level of utility since the majority of people being screened derive no benefit from having the test done. Because the vast majority of people who are screened do not have the disease, they get minimal reassurance from a negative test because their pretest probability of disease was low before the test was even done. However, for many people, the psychological relief of having a negative test, especially for something they are really scared of, is a worthwhile positive outcome. Usual diagnosis in patients Treatment resulting in presenting with signs or prolonged period of time symptoms of disease. The second rule is that the prevalence of the disease matters and as the prevalence decreases, the number of false positives increases and relative number of true positives to false positives decreases. The final rule is that the burden of proof regarding efficacy depends upon the clinical context, which can depend on multiple factors. If the interven- tion is innocuous and without side effects, screening should be done more often than if the intervention is dangerous, high-risk, or toxic. Similarly, if the test or treatment is very expensive, the level of proof of benefit of the screeing test must be greater. During the 1950s the executive physical examination was used to screen for “all” diseases in corporate executives and other, mostly wealthy, people. It was a comprehensive set of diagnostic tests including multiple x-rays, blood tests, exercise stress tests, and others, usually administered while the patient spent a week in the hospital. It was justified by the thought that finding disease early was good and would lead to improved length and quality of life. The more dis- eases looked for, the more likely that disease would be found at an earlier phase in its course and treatment at this early stage would lead to better health out- comes. Subsequent analysis of the data from these extensive examination pro- grams revealed no change in health outcomes as a result of these examinations. There were more people incorrectly labeled with diseases that they didn’t have than there were diseases detected early enough to reduce mortality or morbidity. Ironically, most of the diseases that were identified in these programs could have been detected simply from a comprehensive history. In this case most of the positive tests are false positives and the further testing that is required to determine wether the test is a false or true positive usually requires invasive testing such as operative biopsy. Finally, 312 Essential Evidence-Based Medicine Table 28. Criteria for a valid screening test (1) Burden of suffering The disease must be relatively common. Criteria for screening There are five criteria that must be fulfilled before a test should be used as a screening test. Following these rules will prevent the abuses of screening tests that occurred in the 1950s and 1960s and which continue today.

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The good news is that a wealth of advice is available for those who Case resolution seriously want to acquire good time management techniques 2mg prandin with amex. The resident decides to talk to a staff member they respect The key competencies are knowing oneself order prandin 0.5mg visa, prioritizing and about this fatigue. They have a great conversation, and setting goals, following a plan, getting organized, and leverag- the resident feels hopeful. Becoming personally effective requires insight the weekend off medicine, spend some quality time with into one’s priorities, strengths, weaknesses and values. The resident will then can one set priorities in alignment with one’s fundamental also take some time to refect on how they organize their goals. Techniques to assist prioritizing include values clarif- week to see if they can “work smarter. Techniques in this domain include set- ting personal and professional goals (short-, medium- and Key references long-term) and using a personal organizer (e. Shiftwork, fatigue, and safety in emergency career trajectory are examples of roadmaps to success. Patient Safety in Emergency the most out of these priorities, a well-organized work space Medicine. Finally, it is important to manage available resources, whether assistants, colleagues, mentors, or technologies. Other forms of intimidation and • discuss the elements of intimidation and harassment and harassment reported by resident physicians have included inap- how they affect residents during training, and propriate physical contact, sexual harassment, the assignment • describe an approach to dealing with intimidation and of work as a punishment, loss of privileges and opportunities, harassment within the context of a residency program. Dealing with intimidation and harassment Case For intimidation and harassment to be tackled effectively, it is Your residency program is under accreditation next year. In some cases, it is faculty who may you will institute as a faculty administrator to prepare for be more concerned about the repercussions of reporting for this event? On the fip side, trainees should recognize that, in many cases, the individuals Introduction involved in bullying are not aware of the effect they are hav- Intimidation, harassment and workplace bullying have prob- ing. In many cases, individuals who intimidate and/or harass ably existed as long as the institution of medicine, but have others need education in effective communication as teachers started to be addressed by medical faculties only within the last and administrators, rather than disciplinary action. At a fundamental level, intimidation and harass- cal schools have now adopted directors or deans of equity to ment are defned not only by the behaviour and motivations deal with confict issues between faculty and trainees. Many of the perpetrator, but by the response of the individual who of these individuals directly report to the dean of medicine or is targeted. It should be seen as causing a negative effect on to “high-level” faculty committees with the ability to institute the victim (e. They focus on the content, psychological issues and or harassment is ever appropriate, such acts must be persistent procedures surrounding the issue of confict. Program directors, faculty members and importance of reporting such events, not only so that medical residents must be aware of these resources and deem them trainees can protect themselves, but also to help prevent their to be effective in dealing with such concerns. By taking action against bullying are unable to demonstrate such mechanisms may be put on behaviours, medical students and resident can help to change probation and risk losing their accreditation status. In tying such importance to this issue, the Royal College ensures Where intimidation and harassment leads that programs will endeavour to create a training environment Intimidation and/or harassment can lead to poor job satisfac- that limits intimidation and harassment, adequately deals with tion and psychological distress. It has been associated with issues that arise, and takes steps against the perpetuation of mental health problems and a desire to leave medical train- unacceptable behaviours, for the beneft of future generations ing. Where intimidation and harassment occur Physicians in training experience intimidation and/or harass- ment in all areas of medical training—that is, in the clinical, research, administrative and political realms. More than half of respondents to a recent Canadian survey reported that they had experienced intimidation and/or harassment while in residency training. Training status and gender were felt to be the two main bases for the intimidation and/or harassment. The happy docs teaching faculty are aware of policy and procedures for study: a Canadian Association of Internes and Residents well- dealing with intimidation and harassment (e. A meeting could be organized with the tion within and outside of residency training in Canada. This may be done with a teaching session using case examples or role playing from the director of equity. Residents should also be encouraged not to conceal, but rather report concerns around intimidation and harass- ment so that the accreditation team can make appropriate recommendations that will ultimately be addressed by the individual programs. Challenges to collegiality are dis- Collegiality involves certain rights and is tempered by specifc cussed with respect to disruptive physician behaviours, confict obligations. In academic contexts, it pertains to a commitment management, and gender-based and generational tensions. Collegiality allows physicians to educate one an- on the health care team are discussed. Physicians have an obligation to put restrictions Resident leaders, medical educators and program directors on their collegiality: in particular, they must give the welfare of should all endeavour to foster collegiality in professional rela- their patients priority over their collegial relationships. One method of doing so is to encourage the mentor- ing of residents by faculty members, and of medical students Although collegiality is highly prized by individual practitioners by residents, whether in person, by email or through websites. One cannot become an effective Scholar and Medical academic half-days), between supervisors and residents, and Expert without sharing information with peers. As a body, residents be an effective Health Advocate without the cooperation of can decide on a topic concerning physician health that could one’s supervisors and peers—which will itself be shaped by be mediated by increased collegial relations (e. One learns stress related to time pressures in training) and invite a faculty effective approaches through the wisdom and example of member who feels comfortable sharing personal experience to other practitioners. To fulfll the general observation, more formal methods include a 360 de- obligations of their Professional Role with respect to patient gree evaluation process by which residents are evaluated by all care, ethical behaviour and self-regulation, physicians cannot members of the health care team, including their peers. In addition to supporting these domains feedback is often perceived as less critical and constructive of competency, collegiality by defnition engenders the kind of in criticism, when discussing topics of communication with mutual respect and support that helps to prevent the intimida- colleagues. This kind of evaluation process can ensure that the tion and harassment of colleagues. Moreover, where healthy resident is evaluated fairly by all members of the team and collegiality exists, physicians will not only support one another removes pressure off of the physician preceptor who may during good times, but will also protect one another’s health by have challenges providing critical feedback. For the residents recognizing when colleagues are in trouble and helping them involved, it builds skills in giving feedback on professional to get the support they need. Ottawa: departments that do not foster collegiality suffer from poor The Royal College of Physicians and Surgeons of Canada. Collegiality is an important predictor of job satisfaction, and Bulletin of the New York Academy of Medicine. For example, learning can be facilitated by group ac- and tivities such as workshops and tutorials.

Inaddition buy prandin 0.5mg without a prescription,theuseofalbumin r Patients at risk of cardiac failure (elderly buy 0.5mg prandin amex, cardiac solution in hypoalbuminaemic patients (which seems disease, liver or renal impairment) require special logical)hasbeenassociatedwithincreasedpulmonary caution as they are more prone to develop fluid oedema,possiblyduetorapidhaemodynamicchanges overload. The Fluid regimens: These should consist of maintenance choice of fluid given and the rate of administration fluids (which covers normal urinary, stool and insensible depend on the patient, any continued losses and all losses) and replacement fluids for additional losses and patients must have continued assessment of their fluid to correct any pre-existing dehydration. Fluid regimens balance using fluid balance charts, observations and must also take into account that patients of differing 10 Chapter 1: Principles and practice of medicine and surgery Table1. Bothhypokalaemiaandhyper- blood as shown by the equation and so acutely com- kalaemia (see page 7) are potentially life-threatening and pensates for acidosis. The kidney is able to potassium is dangerous, so even in hypokalaemia no compensate for this, by increasing its reabsorption of more than 10 mmol/h is recommended (except in se- bicarbonate in the proximal tubule. The pH is first examined to see if the patient is acidotic or Atypical daily maintenance regime for a 70 kg man with alkalotic. The base In general, dextrosaline is not suitable for mainte- excess is defined as the amount of H+ ions that would be nance, as it provides insufficient sodium and tends requiredtoreturnthepHofthebloodto7. Replacement fluids base excess signifies a metabolic alkalosis (hydrogen ions generally need to be 0. In chronic respiratory be remembered that intravenous fluids do not provide acidosis renal reabsorption of bicarbonate will reduce any significant nutrition. Normally r Acidosiswithlowbicarbonateandnegativebaseexcess hydrogen (H+)ions are buffered by two main systems: defines a metabolic acidosis. If the patient is able the r Proteins including haemoglobin comprise a fixed respiration will increase to reduce carbon dioxide and buffering system. Causes of metabolic aci- Pathophysiology dosisincludesalicylatepoisoning(seepage528),lactic Hypercalcaemia prevents membrane depolarisation acidosis or diabetic ketoacidosis (see page 460). Al- leadingtocentralnervoussystemeffects,decreasedmus- ternatively failure to excrete acid or increased loss of cle power and reduced gut mobility. Hyperkalaemia may occur as an im- rate;itcan cause acute or chronic renal failure; it can also portant complication (see page 7) particularly if there causenephrogenicdiabetesinsipidus(seepage445),uri- is also acute renal failure. This may result from any cause of hyperven- ening of the Q–T interval but this is not associated with tilation including stroke, subarachnoid haemorrhage, an increased risk of cardiac arrhythmias. Early symptoms be caused by loss of acid from the gastrointestinal are often insidious, including loss of appetite, fatigue, tract (e. Hypokalaemia may occur toms of hypercalcaemia can be summarised as bones, (see page 8). Deposition of calcium in heart valves, coronary Aetiology arteries and other blood vessels may occur. Hyper- Important causes of hypercalcaemia are given in tension is relatively common, possibly due to renal im- Table 1. More than 80% of cases are due to malignancy pairment and also related to calcium-induced vasocon- or primary hyperparathyroidism (see page 446). The serum calcium should be checked and r Bisphosphonates can be used, which inhibit bone corrected for serum albumin because only the ionised turnoverandthereforereduceserumcalcium. Serum phos- Aetiology phate may be helpful, as it tends to be low in ma- Hypocalcaemia may be caused by r vitamin D deficiency, lignancy or primary hyperparathyroidism but high in r hypoparathyroidism (after parathyroidectomy, thy- other causes. Pathophysiology r Patients should be assessed for fluid status and any Hypocalcaemia causes increased membrane potentials, dehydration corrected. Rehydration reduces calcium which means that cells are more easily depolarised levels by a dilutional effect and by increasing renal and therefore causes prolongation of the Q–T interval, clearance. Intravenous saline is often needed because which predisposes to cardiac arrhythmias. It may also many patients feel too nauseous to tolerate sufficient cause refractory hypotension and neuromuscular prob- oral fluids and polyuria is common due to nephro- lems include tetany, seizures and emotional lability or genic diabetes insipidus. Chapter 1: Perioperative care 13 Clinical features Perioperative care The condition may be asymptomatic and diagnosed in- cidentally on calcium measurement. The preoperative assessment Neuromuscular manifestations Underlying any decision to perform surgery is a recog- Early symptoms include circumoral numbness, paraes- nition of the balance between the risk of the procedure thesiae of the extremities and muscle cramps. All patients un- but less specific symptoms include fatigue, irritability, dergo a preoperative assessment (history, examination confusion and depression. Myopathy with muscle weak- and appropriate investigations) both to review the diag- ness and wasting may be present. Carpopedal spasm nosis and need for surgery, and to identify any coexisting and seizures are signs of severe hypocalcaemia. Elici- disease that may increase the likelihood of perioperative tation of Trousseau’s sign and Chvostek’s signs should complications. In general any concerns regarding coex- be attempted, although it can be negative even in severe isting disease or fitness for surgery should be discussed hypocalcaemia: with the anaesthetist who makes the final decision re- r Trousseau’s sign: Carpal spasm induced by inflation of garding fitness for anaesthesia. Cardiac disease by history, examination and, where appropriate, failure may occur. Elective surgery should be deferred by at caemia to guide management and to look for the under- least 6 months wherever possible. The serum calcium should be checked and r Hypertension should be controlled prior to any elec- corrected for serum albumin (see above). Blood should tive surgery to reduce the risk of myocardial infarction also be sent for magnesium, phosphate, U&Es and for or stroke. Chronic or complex arrhythmias should be Management discussedwithacardiologistpriortosurgerywherever This depends on the severity, whether acute or chronic possible. Mild hypocalcaemia is treated r Patients with signs and symptoms of cardiac failure with oral supplements of calcium and magnesium should have their therapy optimised prior to surgery where appropriate. Severe hypocalcaemia may be life- and require special attention to perioperative fluid threatening and the first priority is resuscitation as balance. Calcium gluconate contains only a third of the with a history of bacterial endocarditis should have amount of calcium as calcium chloride but is less irritat- prophylactic oral or intravenous antibiotic cover for ing to the peripheral veins. Patients must be asked pulmonary embolism, is a significant postoperative about smoking and where possible should be encour- risk. Risk factors include previous history of throm- aged to stop smoking at least 6 weeks prior to surgery. Wherever possi- cated unless there are acute respiratory signs or severe ble, risk factors should be identified and modified (in- chronic respiratory disease with no film in the last cluding stopping the combined oral contraceptive pill 12 months. Preop- coagulant or antiplatelet medication and chronic liver eratively all therapy should be optimised; pre- and disease may cause perioperative bleeding.

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