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By G. Lisk. Marywood University. 2018.


The Level 1 outcomes and ‘Medical professionalism’ are suitable for implementation as “curriculum themes” purchase 250 mg naprosyn amex, and applications such as blue-printing of assessment programmes generic naprosyn 500 mg with visa. The Level outcomes may be used to determine discrete items of teaching discount 250 mg naprosyn overnight delivery, learning and assessment. The outcomes are available for use by educational managers in curriculum planning, or as part of quality enhancement or quality assurance processes. These would provide the core learning outcomes of a primary medical degree programme, although each country, medical school and student would also be expected to achieve additional learning outcomes tailored to their local and individual needs. If applied appropriately and linked to efective assessment, this approach allows each school or country to have a distinct profle and to focus on particular areas of strength (e. Such concerns led to the Bologna Declaration (European Ministers of Education, 1999) and the ongoing ‘Bologna Process’ which seeks to create a system of easily readable and comparable degrees and the establishment of a European Higher Education Area. A three-cycle system of higher education degrees - Bachelors, Masters and Doctorate - normally equating to two or three years of study each. The “Dublin Descriptors” are generic outlines of the level of academic achievement for each cycle (Joint Quality Initiative informal group, 004). A qualifcations framework describing the typical learning outcomes/ competences for each cycle and discipline. The Tuning Project Making vocational degree qualifcations comparable and easily readable is at the heart of the Bologna Process. Methods of achieving this based purely on duration of study are fallible and give little information as to how graduates will perform in the workplace. A more robust outcome-based approach was developed by the Tuning Project (http://tuning. Initiated in 000, the Tuning Project is led by Julia González (University of Deusto) and Robert Wagenaar (University of Groningen). Several disciplines, including nursing, developed learning outcomes during the initial phases of the Tuning Project (Tuning Educational Structures in Europe. They describe particular items of learning related to a component of a degree programme, such as a lecture, tutorial, module or attachment. Learning outcomes are also set and described by teaching staf, but refer to the whole degree programme and relate to the point of graduation. They are usually specifed with a hierarchy of levels, with a top level consisting of large domains of learning. Competences are acquired by, and belong to, students or graduates, rather than teachers. For a graduate who has successfully completed the degree programme, their competences should be at least equivalent to the prescribed learning outcomes (although they are very likely to have developed further in particular areas of learning). In that sense, when referring to the point of graduation, specifed learning outcomes can be viewed as equivalent to core graduate competences, and the same descriptors can be used. The Tuning Project (Medicine) is led by the University of Edinburgh, with a local steering group and a European Task Force (Appendix C). Previous work A great deal of work has already been done to defne curriculum-level outcomes/ competences for medical education. Many other national and institutional outcomes frameworks have been developed in Europe and elsewhere. Process and methods The Tuning Project (Medicine) was funded by the European Commission on the basis that the methodology would be similar and results comparable with the “parent” Tuning Project (Tuning Educational Structures in Europe. Existing learning outcomes/competency frameworks were reviewed by the Project steering group. A preliminary draft learning outcomes framework for Tuning (Medicine) was generated by the Project steering group. In a series of European workshops, members of the Tuning (Medicine) Taskforce sequentially reviewed and refned the draft document in the light of expert opinion and the Internet opinion survey (see below). Workshops were held in Budapest (April 005), Amsterdam (September 005), Edinburgh (February 006), Prague (May 006), Genoa (September 006), Oslo (May 007) and Antalya (September 007). In addition, presentations of the draft framework were made and feedback obtained at numerous other meetings in Europe and elsewhere.

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Sex r If chronic order naprosyn 500mg amex, the crystals accumulate in the synovium 10M:1F and sites such as the ear cartilage forming lumps termed tophi order 500mg naprosyn with amex. Theresultof urate damage is either tubulointerstitial disease (urate Aetiology nephropathy) or acute tubular necrosis naprosyn 500 mg with mastercard. High levels of uric acid cause gout but not all individuals with hyperuricaemia will develop gout. Hyperuricaemia Clinical features is associated with increasing age, male sex and obesity, In 70–90% the initial attack of gout affects the big toe. These features ratesofuricacid production or decreased uric acid make it difficult to distinguish from a septic arthritis. Other joints affected include ankles, knees, fingers, el- r Increased uric acid production may be idiopathic or bowsandwrists. Chronicgoutisunusualbutmaycausea secondary to excessive intake or high turnover as seen chronic polyarthritis with destructive joint damage with in malignancy (especially with chemotherapy). Chapter 8: Metabolic bone disorders 373 Investigations Management Urate levels are often high, although they may fall during The pain of pseudogout is relieved by nonsteroidal anti- an acute attack. Metabolic bone disorders Management Acute gout is managed with high dose nonsteroidal anti- inflammatory drugs. Hyperuricaemia is treated only if Osteoporosis associated with recurrent gout attacks. Definition r Non-pharmacological: Weight loss, high-fluid intake, A disease characterised by low bone mass and microar- low alcohol, low-purine diet, avoid thiazides and as- chitectural disruption. Excess purines are excreted as xan- thine rather than uric acid, and the therapy is lifelong. Overall 30% of individuals will have a pathological frac- ture due to osteoporosis. It is thought that osteoporosis rophosphate production leads to local crystal formation. The risk of fractures increases with bone shed from the cartilage in which they have formed. Factors that can affect the re- modelling balance are as follows: r Sex: Females have a lower bone mass and a high rate of Clinical features bone loss in the decade following the menopause. This Chondrocalcinosis may be detected on X-ray in cartilage is largely oestrogen-dependent, early menopause and without joint disease. Acute joint inflammation resem- ovariectomy without hormone replacement therapy bles gout most commonly affecting the knee and other predisposes. Examination of the joint fluid will demonstrate posi- r Genetic factors implicated include the vitamin D re- tively birefringent crystals. Aetiology Pathophysiology Osteomalacia is usually due to a lack of vitamin D or its Although there is low bone mass it is normally min- activemetabolites,butitmaybecausedbyseverecalcium eralised. The structural integrity of the bone is During bone remodelling vitamin D deficiency results in reduced, causing skeletal fragility. Clinical features Osteoporosis is not itself painful; however, the fractures that result are. Typical sites include the vertebrae, distal Clinical features radius(Colles’fracture)andtheneckofthefemur. Other Onset is insidious with bone pain, backache and weak- symptomsofvertebralinvolvementarelossofheightand ness that may be present for years before the diagnosis is increasing kyphosis. Vertebral compression and pathological fractures may occur; a biochemical diagnosis may be made prior Investigations to onset of clinical disease. Investigations r X-rayinvestigationshowsfractures,abonescancanbe r X-ray investigation shows generalised bone rarefac- used to demonstrate recent fractures. Looser’s zones bone density is difficult to assess as the appearance is may be seen in which there is a band of severe rarefac- dependent on the X-ray penetration. Maleswith A disorder of bone remodelling with accelerated rate of gonadal failure benefit from androgens. Chapter 8: Genetic musculoskeletal disorders 375 Prevalence calcium level may rise dramatically.

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Anuria (no It is important to take a history buy cheap naprosyn 250mg, which may suggest a urine) suggests that the urinary tract is obstructed cheap 250mg naprosyn, ei- cause: ther bladder outflow buy naprosyn 500mg low cost, or both kidneys, or a single func- r Dysuria suggests cystitis. This should be treated, then tioning kidney (which will, if not rapidly treated, go on urine re-tested to ensure the haematuria has cleared. Polyuria is the passage of in- r Renal colic, or a previous history of urinary stones. Urine the urine dipstick is vital and considered part of the clinical exam- Haematuria Cause ination. Renal Glomerular Disease Investigations Polycystic Kidney Disease Transient microscopic haematuria (without protein- Pyelonephritis Trauma uria) without any other symptoms or signs is generally Carcinoma (renal cell, transitional cell) benign, and may be followed up clinically in young in- Vascular malformations, emboli dividuals. Extra-renal Cystitis, Prostatitis, Urethritis Separate samples of urine can be collected on com- Urinary stones mencing micturition, midway through micturition and Trauma Neoplasm (papilloma, bladder at the end of micturition (the three-glass test). Urinary tract infections with bacteria such as Investigations and procedures Proteus, which produce urease, cause the urine pH to rise to neutral or even alkaline levels. Urine tests Dipstick testing Quantification of proteinuria The basic test includes blood, protein, glucose, specific This is done on patients who have persistent proteinuria. If truly positive, it should be investigated as for random urine specimen and is accurate, straightfor- haematuria (see page 224). Inthe United Kinddom, urinary creatinine is ex- such as immunoglobulin light chains (Bence Jones pressed in mmol/L so the result needs to be multiplied protein) which require specific tests. Glucose is not normally found in Patients with proteinuria, which is greater than normal the urine until the plasma glucose concentration is butlessthandetectableondipstick,have‘microalbumin- ≥10 mmol/L. This is defined as albumin excretion of between 35 an inability of the kidney to reabsorb filtered glucose and 200 mg/24 hour. It is an early indicator of diabetic due to dysfunction in the proximal tubule, such as kidneydisease,andisalsofoundinotherconditionssuch occurs in multiple myeloma, renal tubular acidosis ascardiovasculardiseaseevenwithoutrenalimpairment. Causesin- Physiological (up to Fever 300mg/24h) clude cystitis, tubulointerstitial nephritis and calculi. Extra-renal causes Diabetes mellitus r Bacteria: Visible bacteria may be due to contamina- (most of these cause Pre-eclampsia tion of the specimen, or a urinary tract infection. Aetiology r Casts: These are cylinders formed in the renal tubules Causes of proteinuria include those shown in Table 6. In glomerular or tubular Pathophysiology disease, cells in the urine become incorporated into The glomeruli normally filter 7–10 g of protein per the casts. Red cell casts are diagnostic of glomerular 24 hours, but less than 2% of this is actually excreted disease. White cell casts occur in tubulointerstitial because protein is actively reabsorbed in the proxi- disease and pyelonephritis. Normal urinary protein excretion is <150 as granular or epithelial cell casts exist. In hypona- 2 Glomerular proteinuria is due to increased permeabil- traemia, a low urinary sodium is physiological, whereas ity of the glomerular basement membrane. Heavy with a normal serum sodium, a low urinary sodium in- proteinuria (>3 g/day) is termed nephrotic range dicates salt-and-water depletion (dehydration). Following abdominal or pelvic surgery, it can and oedema is termed nephrotic syndrome. Urinary β2-microglobulin can be used as a mea- these are similar to the urine urea and creatinine con- sure of tubular function, because this small peptide centrations, this indicates a urinary leak. The proteinuria is usu- ally mild in tubular disease, such as in acute tubular Proteinuria necrosis or pyelonephritis. Definition 4 Increased secretion of protein (Tamm–Horsfall pro- Agreater than normal amount of protein in the urine. Microalbuminuria (30–200 mcg albumin/24 h or an early morning urine albumin:creatinine ratio >3) pre- dicts mortality and renal failure in diabetes mellitus and Clinical features cardiovascular deaths in the elderly. It also occurs in Proteinuria is usually asymptomatic, although heavy hypertension, myocardial infarction and as part of the proteinuria may be noticed as frothy urine, or if acute phase response. Protein excretion in- creases in the upright position, and proteinuria, which disappears on early morning collection before ambula- Imaging of the urinary tract tion is called orthostatic proteinuria, a benign condi- tion affecting 2–5% of adolescents, but uncommon over Plain X-ray of the kidneys, ureters and the age of 30 years. The outlines of the kidneys are unreliably seen because of overlying bowel Investigations gas. All positive urine dipstick measurement of protein should be confirmed by laboratory testing.

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Support translational research infrastructures plied and propagated so as to become standard practice in and enforce data harmonisation fostered by health generic 500 mg naprosyn with mastercard. Develop and encourage the fast uptake of tech- • Give access to data from silos by encouraging and faci- nologies for data capture purchase naprosyn 500mg overnight delivery, storage naprosyn 250mg with amex, manage- litating data sharing. Support analytical methods and modelling way that data are stored, secured and shared, respec- approaches to develop new disease models, e. This requires the following another patient who has the same fngerprint (‘electronic actions: twin’), whose electronic medical record of natural history of disease and treatment outcome will help medical de- • Harmonise the format in which big data are collected cision-making through modelling and prediction. The introduction of genomic (sequence) and molecular • Decide which data will be needed (e. Ministries of health, research ributes to the accuracy of the diagnosis/treatment and justice; institutions for public health and health scheme, e. Create a European ‘big data’ framework and ad- public research bodies including systems biology/me- apt legislation. To leverage this huge potential beneft for patients and citizens, healthcare professionals need to strengthen a. In parallel they need suitable deci- sion-support tools with an easy-to-use interface to make The establishment of the pan-European Research In- their use in clinical routine possible. Electronic health records are and interoperability of big data generated by the re- being introduced into public and private healthcare in most search infrastructures and communities. The availability of very large tifcation is dependent on the results of such research. Furthermore Member States works currently work on collections of very large disea- 21 se-specifc sample and data collections. This is a national network of centres of excellence linking clinical and In France the National Research Strategy (April 2015), research data to address a range of research questions. This programme is part of a national action frame- between Member States, and interoperability of he- work launched in 2014, making 100 million € availab- alth-related registries and health records is a major le for fve years. This context can include micro-orga- lent basic science with clinical and public health research nisms and their characteristics. Given that some of the and through product development and communication mechanisms of expression, interaction and signifcance in both directions. This will require the concerted action are not well understood, it is crucial to continue to seek of a number of sectors, disciplines and agencies. In recent not only to improve the knowledge base, but to develop years, there have been a number of scientifc and tech- meaningful interventions that will positively impact nological breakthroughs underpinning the usefulness of upon an individual’s health. These have been achieved environment on the evolution of disease could have sig- through a number of largely ‘bottom-up’, investigator-dri- nifcant clinical impact. Research into the underlying genetics of di- seases must continue as this will identify new targets for 16. Support research in preclinical models to valida- treatment as well as new biomarkers of disease. It is evi- te hypotheses resulting from molecular analy- dent that basic research has a crucial impact on clinical ses of patient samples and treatment outcomes. Basic research can result in new insights that need to be explored in a cli- Targeted achievements until 2020 and beyond – Re- nical setting. However, nature is often more complicated commendations than we realise, and therefore it is of critical importance that clinical observations resulting from the translation of 15. Develop methods to better integrate and basic insights are fed back into the laboratory in order to evaluate the information provided by genomic, improve our understanding of underlying mechanisms. This information can then be used to adapt pro- patterns – even at the single cell level – is growing ex- tocols resulting in more efective treatments. Illustrative ponentially, there are great difculties in interpreting this examples of this already exist in the treatment of cancer, information.

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