Modules

• Year 1
  • Introduction to Year 1 and Year Outcomes
  • Fundamentals of Medicine
  • Cardiorespiratory 1
  • Metabolism 1
  • Locomotor 1
  • Brain and Behaviour 1
  • Human Development 1
  • Medicine in Society 1
  • Clinical Communication Skills
  • Student Selected Component (SSC)
• Year 2
  • Introduction to Year 2 and Year Outcomes
  • Cardiorespiratory 2
  • Metabolism 2
  • Brain and Behaviour 2
  • Human Development 2
  • Human Sciences and Public Health 2
  • Locomotor 2
  • Cancer Week
  • Moving and Handling Training
  • Year 2 Lifesaver Programme
  • Clinical Communication Skills
  • Medicine in Society 2
  • Extended Patient Contact
  • Student Selected Component (SSC)
• Year 3
  • Introduction to Year 3 and Year Outcomes
  • Clinical Science and Professionalism (Weeks 1-3)
  • Cardiovascular, Respiratory and Haematology (CR3)
  • Gastroenterology and Cancer (MET3A)
  • Public Health
  • Endocrinology and Renal Medicine (MET3B)
  • General Practice and Community Care
  • Student Selected Component (SSC)
  • Clinical and Communication Skills
• Year 4
  • Introduction and Year 4 Outcomes
  • Obstetrics and Gynaecology
  • Child Health
  • HIV & Sexual Health
  • Musculoskeletal
  • Health Care of the Elderly
  • Neuroscience
  • Dermatology
  • General Practice and Community Care
  • Psychiatry
  • Ear, Nose and Throat
  • Global Health and Ethics
  • Ophthalmology
  • Clinical & Communication Skills
  • Student Selected Component (SSC)
• Year 5
  • Introduction to Year 5 and Year Outcomes
  • Teaching Week 1
  • Teaching Week 2
  • Anaesthesia & ITU (AN & ITU)
  • Breaking Bad News
  • Clinical Pharmacology & Therapeutics
  • Community Care
  • Doctors as Teachers and Educators (DATE)
  • Emergency Medicine (EMERG MED)
  • General (Internal) Medicine (G(I)M)
  • Immediate Life Support (ILS)
  • Student Assistantship
  • Simulation
  • Surgery
  • Student Selected Component (SSC)
• Year GEP 1
  • Cancer Week
  • Movement and Posture
  • Carriage of Oxygen
  • Human Sciences and Public Health
  • Digestion, Growth and Metabolism
  • Infection and Immunity
  • Ethics
  • Brain and Behaviour
  • Human Development
  • Clinical Communication Skills
  • Medicine in Society (GEP)

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Year 3 CSP3: Clinical Science and Professionalism (Weeks 1-3)

• Ms Adrienne Kirk
• adrienne.kirk@qmul.ac.uk

Teaching Material for this Module

Introduction

This module develops further knowledge and understanding, and practical skills where appropriate, on the areas of clinical pharmacology, microbiology, haemostasis, heamatological oncology, public health, ethics, autoimmunity and transplantation, immune response and immune deficiency and genetics.

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Index

• General Outcomes for the Whole Person
• Infective Endocarditis (Priority 2*)
• Asthma (Priority 1*)
• Pneumonia (Priority 1)
• Cancers of Blood and Lymph (Priority 3)
• Diarrhoeal and Inflammatory Disorders
• Bladder Dysfunction and Urinary Tract Infection
• HIV Infection
• CNS Infections
• Inflammatory Skin Disease

• General Outcomes for the Whole Person
  • Medical knowledge: MOLECULAR BIOLOGY and GENETICS (TD 8.5, 8.6)
    • Genetics of Autoimmune Disease
      1. Understand how genetic risk variants predisposing to human disease can be identified
      2. Understand the spectrum of risk variants (common, rare, SNPs, structural variants)
      3. Understand risk variants for selected chronic immune disease eg Type 1 Diabetes, Coeliac Disease, Crohn's Disease
      4. Role of HLA variants and immune disease risk: coeliac disease, ankylosing spondylitis as examples
      5. Role of new technologies: exome and whole genome sequencing.
      6. Taking risk variants forward for patient benefit: diagnosis, prognosis, new therapeutics
    • Genetics of Antibiotic Resistance
      1. Be able to describe the key features of plasmids, insertion sequences, transposons and integrons and understand their role in mobility of antibiotic resistance genes.
      2. Be able to understand the differences between bacterial and eukaryotic genes
      3. Be able to outline the mechanism of transfer of DNA between bacterial cells; conjungation, transformation and transduction
      4. Know the major biochemical mechanisms of resistance - destruction of drug, modification of drug, drug impermeability or efflux, target modification, target bypass
      5. Understand that resistance can disseminate by spread of resistant strains, spread of mobile genetic elements and spread of resistance genes
      6. Understand the potential sources of antibiotic resistance genes and the significance of horizontal gene transfer in the evolution and spread of antibiotic resistance among pathogenic bacteria
    • Genetics - General Outcomes
      1. To be able to define the differences between monogenic and complex genetic diseases
      2. What? The type of alteration of genetic material: molecular and cytogenetic, and subdivisions.
      3. To have some knowledge of the methods used to map genes causing complex genetic diseases, for example the basics of linkage analyses and association studies
      4. How? (type of molecular biological consequence)
      5. Where? (which cells are affected)
      6. To know some examples of complex gene traits where new genes have been mapped and what has been found and why it is important
      7. Who? (patterns of inheritance)
      8. When? (at what point is the disease visible)
      9. These questions are applied to the following diseases in differing amounts of detail: Duchenne muscular dystrophy, Haemophilia A, X-linnked severe combined immune deficiency disorder, congenital deafness, Retinitis pigmentosa, Chondroplasia punctata, Hypophosphataemic rickets, Cystic fibrosis, Tay-Sachs, Haemachromatosis, Phenylketonuria,.Huntingdons disease, Achondroplasia, polycystic kidney, Fragile X mental retardation, Alzheimer’s disease, Down’s syndrome, Acquired uniparental disomy, Reigar syndrome, Preaxial polydactyly
      10. Duchenne muscular dystrophy, Haemophilia A, X-linked severe combined immune deficiency disorder, congenital deafness, Retinitis pigmentosa, Chondroplasia punctata, Hypophosphataemic rickets, Cystic fibrosis, Tay-Sachs, Haemachromatosis, Phenylketonuria,.Huntingdons disease, Achondroplasia, polycystic kidney, Fragile X mental retardation, Alzheimer's disease, Down's syndrome, Acquired uniparental disomy, Reigar syndrome, Preaxial polydactyly
      11. Gene therapy: the characteristics of a particular genetic disease that render gene therapy likely or unlikely to be successful.
  • Medical knowledge: IMMUNOLOGY and INFLAMMATION (TD 8.8)
    • The Immune Response in Health
      1. List the physical defence barrier components of the innate immune system (skin etc), and link them with the mechanisms by which they are breached
    • Transplantation and Immunosupressive Therapy
      1. List the meanings of autograft, isograft, allograft and xenograft.
      2. Understand the role of Class 1 and Class II HLA molecules in presenting antigen to CD8 and CD4 T-lymphocytes respectively, and the ability of foreign Class I and II HLA (or xenogeneic equivalent) to directly activate some CD8 and CD4 T-lymphocytes.
      3. Understand and know the timing of the terms: Hyperacute rejection (mediated by antibodies against Graft HLA molecules + complement), Accelerated rejection (mediated by presensitised T-lymphocytes), Acute rejection mediated by T-lymphcytes, and chronic rejection (uncertain mechanisms).
      4. Know the role of IL2 and IFNy in promoting T-lymphocyte reactivity, and of IL4 and 6 in producing anti-graft antibodies.
      5. Understand the role of recipient antibody screening, and of cross matching in prevention of hyper-acute rejection.
      6. Understand that bone marrow transplant carries the additional risk of Graft-versus-Host.
    • Hypersensitivity and Allergy
      1. Mostly revision: definitions of allergy, atopy, types of hypersensitivity, activation of mast cells, anaphylaxis, anaphylactoid reactions, scromboid and the antigens that provoke them
      2. Urticaria: description, and the different causes (allergic, infections, autoimmune, cold, cholinergic/adrenergic, physical, exercise, hormonal, haematinic deficiency) and treatment
      3. Angioedema: description, causes (allergic, inherited, acquired C1 esterase deficiency, ACE inhibitors, idiopathic) and treatment
    • Immunology - General Outcomes
      1. Identify patients at risk of immunodeficiency
      2. Identify clinical features suggestive of deficiency of Non-specific defences; Neutrophils; Antibody; T-Lymphocytes ('combined') deficiencies
      3. Understand principles of management of immune deficient patients
      4. Distinguish the features of the following conditions: conjunctivitis/rhinitis/sinusitis, asthma, atopic dermatitis, aspirin sensitivity, oral allergy syndrome, other food allergy, latex allergy, drug allergy, erythema multiforme and Stevens-Johnson syndrome
      5. List features of the following primary immunodeficiency syndromes: Common variable immune deficiency, X-linked agammaglobulinaemia, Di George syndrome, Severe combined immune deficiency, chronic granulomatous disease, Classical complement pathway deficiency, Lytic sequence deficiencies, Chediak-Higashi syndrome, Wiskott-Aldrich syndrome.
      6. Match these tests to their diagnostic indications: total IgE, specific IgE, tryptase, C3, C4, C1q, C2, anti-C1q antibodies, D-dimers, C1 esterase inhibitor, cryoglobulins, skin-prick tests, patch tests
      7. List the features of the following secondary immunodeficiency syndromes: neutropenia, Chronic lymphocytic leukaemia, splenectomy, AIDS, Immunodeficiency due to immunosuppression.
    • Recognition and Response to Antigens
      1. List the cellular components of the innate immune system: macrophages / monocytes; neutrophils; eosinophils; basophils / mast cells; and link them with their antigen T receptors (where known: TLRs, NOD)
      2. State how phagocytes move and kill (together with defects), and state the structures and molecules that they interact with: endothelial cells, adhesion molecules, matrix
      3. List the cells of the adaptive immune system (B-cells, different kinds of T-cells etc), and state the roles they play. List the different classes of antibody
      4. Distinguish between Th1 and Th2 responses and list the cytokines involved in each stating the cells that secrete them
      5. Delineate the mechanism of septic shock
  • Medical knowledge: MICROBIOLOGY and INFECTION (TD 8.9)
    • Antivirals and Viral Infections
      1. Innate and acquired defences against infections
      2. Define humoral and cellular immunity
      3. Iatrogenic and non-iatrogenic causes of immunosuppression
      4. Lists organism causing disease in the immunocompromised host
      5. Outline clinical evaluation and diagnostic procedures
      6. Principles of therapy in the immunocompromised host
    • Retroviruses
      1. List the three sets of genes in retroviruses (Gag, Pol, Env), their order and what they encode
      2. Draw the retroviral life cycle, naming the enzymes involved
      3. List the retroviruses that cause disease in humans and the diseases they cause
      4. Account for HTLV1 causation of Adult T-cell Leukaemia and Myelopathy, including Tax gene; describe these conditions and their treatment
      5. Describe Human Endogenous Retroviruses
    • Antimicrobials and Bacterial Infections
      1. List innate and acquired defences against infection in man.
      2. Define humoral and cellular immunity.
      3. List iatrogenic and non-iatrogenic causes of immunosuppression.
      4. List organisms causing disease in the immunocompromised host relating these to the immunological defect particularly associated with infection by a particular organism.
      5. Outline the clinical evaluation and diagnostic procedures used when investigating the febrile immunosuppressed patient.
      6. List principles of therapy in the immunocompromised host.
      7. List preventive measures employed against infection in known immunosuppressed hosts.
  • Medical knowledge: PHARMACOLOGY (TD 8.10)
    • Drug Monitoring (inc. Therapeutic Drug Monitoring)
      1. Be able to apply therapeutic drug monitoring to the following: Vancomycin Digoxin Gentamicin Phenytoin
      2. Be able to distinguish between the following: Narrow therapeutic window, Half life, Wide therapeutic window, Zero order kinetics, First order kinetics, Trough levels
      3. Demonstrate the ability to appropriately adjust dosage regimens by the use of therapeutic drug monitoring
      4. Describe how to obtain information needed to evaluate plasma drug concentrations e.g. time of sample, history of drug administration, concurrent drug therapy, accurate sample
      5. Know that other drugs that may also require therapeutic drug monitoring e.g. Ciclosporin, lithium
      6. Know the impact of pharmacogenetics on drug dosing, give examples
      7. Recognize the differences between wide and narrow therapeutic windows
      8. Understand the rationale of therapeutic drug monitoring as a guide to therapy and outline areas where it is useful
    • Safe Prescribing and Drug Administration
      1. Define the 10 principles of safe prescribing
      2. Interpret drug dosing information in the BNF
      3. Understand unit conversion and be able to express percentage concentrations
      4. Define and identify the steps involved in Drug reconciliation
      5. Calculate weight-related doses
      6. Define in which patients this is needed and where it should be documented
      7. Identify how to use the BNF to access information about drug treatments
      8. Calculate IV flow rates for drug infusions
      9. Know how to record Allergy status
      10. State the difference between formulations of medicine
      11. Manage the above through a series of worked examples
      12. Understand the risks involved after seeing a video of a medication incident
      13. Identify other sources of information about drugs
      14. Understand the principles of prescribing
      15. Guidelines and policies for antimicrobial prescribing in general
    • Adverse Drug Reactions
      1. Define and distinguish between pharmacodynamic and pharmacokinetic interactions
      2. Define adverse drug reactions (ADRs)
      3. Be able to describe different forms of pharmacokinetic interaction: absorption/distribution/metabolism/excretion
      4. Understand that drug interactions are mostly unwanted and increase patient risk although some are beneficial
      5. Be able to use appendix 1 of the BNF in order to look up information regarding drug interactions
    • Pharmacokinetics and Pharmacodynamics
      1. Define and explain Pharmacokinetics/Pharmacodynamics
      2. Understand uses of PK-PD Modelling
      3. Define Hysteresis and how it is modelled
      4. Understand the importance of Pharmacoeconomics
      5. Understand how outcomes can be improved through use of pharmacodynamics
    • Pharmacological Principles - General
      1. Know what is meant by the term selective toxicity and distinguish between an antibiotic and antimicrobial agent
      2. List sites of action of antimicrobials with examples
      3. List mechanisms of resistance and factors predisposing to increased resistance
      4. Know about the increasing importance of antifungals in medicine and some examples of these agents
    • Drug Interactions
      1. Give examples of antimicrobial side effects and interactions
  • Medical knowledge: PUBLIC HEALTH and GLOBAL HEALTH (TD 11 a-j)
    • Smoking
      1. Describe the pharmacological and psychological aspects of smoking.
      2. Show awareness of existing treatments for smokers, and of their efficacy.
      3. Show basic skills in advising smokers in routine medical consultations.
    • Lifestyle and Disease
      1. Describe the importance of lifestyle factors such as eating and exercise on obesity
      2. Outline some of the difficulties in trying to help people change their lifestyles.
      3. Outline the rationale and efficacy of dietary, behavioural, pharmacological, and surgical treatments for obesity.
      4. Demonstrate skills in providing elementary guidance to obese patients.
  • Professional issues: ETHICS and LAW (TD 20 a-g)
    • Research Ethics
      1. Describe some classical examples of abuse in biomedical research and specify why they are abuses.
      2. Explain the change in ethics and law that has occured in the last four decades
      3. Outline the key international and national codes that currently regulate acceptable research
      4. Describe the work of research ethics committees and the structure of a research protocol.
      5. Identify common moral faults in the design of research protocols and explain why they are faults
      6. Describe the standards of confidentiality in relation to the publication of research outcomes
      7. State the circumstances in which biomedical research could be, or ought not to be, conducted on vulnerable individuals (minors and mentally incapacitated patients)
    • Good Medical Practice: Ethico-Legal Responsibilities of Patient Care
      1. Describe the harm principle and the limits to autonomy
      2. Identify the conflict between the individual and society in the context of risk to others
      3. Outline the steps a doctor should take to ensure that the DVLA is informed about dangerous drivers
    • Management of Medical Information: Truth Telling & Confidentiality
      1. Explain in what respects truth-telling is important both to patient and doctor/student.
      2. Give classical justifications for and against deception and assess the strengh and weaknesses of both.
      3. Specify the potential ethico-legal consequences of lying to patients.
      4. Describe circumstances within medicine and surgery in which it would be appropriate to be economical with the truth
      5. Specify the moral and legal problems of respecting a patient's right not to be told the truth.
      6. Anticipate and appropriately respond to situations where patients ask you as a medical student (or doctor) to be truthful about their condition, treatment and prognosis
      7. Outline good policies on breaking bad news
    • Misconduct, Medical Negligence and Malpractice
      1. Describe the duty of care and who has it
      2. Outline the legal conditions for negligence to be established
      3. Explain the Bolitho modification of the Bolam test
      4. Describe situations or res ipsa loquitur
      5. Explain the legal standard of evidence in negligence cases
    • Legal, Moral, Ethical Responsibilities of Patient Care
      1. Specify the moral and legal problems of respecting a patient's right not to be told the truth.
• Infective Endocarditis (Priority 2*)
  • General Outcomes for Infective Endocarditis
    1. Infective endocarditis: organisms, valves, guidelines for choosing antimicrobial
• Asthma (Priority 1*)
  • General Outcomes for Asthma
    1. List the clinical features of bronchial asthma
    2. List the types and triggers of bronchial asthma
    3. Explain the two phases of asthma and how bronchial hyper-responsiveness is documented
    4. Explain the role of mast cells, eosinophils, dendritic cells, B lymphocytes and CD4 Th1 and CD4 Th2 T-lymphocytes in asthma
    5. Explain the role of IgE, Fcel1, FceRII, IL2, IL3, IL4, IL5, IL13, GMCSF gamma interferon, histamine, leukotrienes, cytokines, adhesion molecules and the Th1/Th2 paradigm
    6. List environmental and genetic factors predisposing to or protecting from asthma
• Pneumonia (Priority 1)
  • Pneumonia - General
    1. Pneumonia: severity (CURB-65 score), guidelines, choice of antimicrobials
• Cancers of Blood and Lymph (Priority 3)
  • General Outcomes for Cancers of Blood and Lymph
    1. The conditions: chronic myeloid leukaemia, polycythaemia rubra vera, essential thromocythaemia, myelofibrosis.
    2. Biology, clinical features, investigations, diagnosis, further tests, management & prognosis of the above conditions.
  • Leukaemia
    1. Definition & consequences of leukaemia.
    2. Cell biology of haemopoietic cells. Differentiation, proliferation, apoptosis.
    3. Classification: Acute lymphoblastic leukaemia, Acute myeloid leukaemia, chronic lymphocytic leukaemia, chronic myeloid leukaemia, myelodysplastic syndrome.
    4. Biology: biological features of each of these diseases..
    5. Clinical features of each of these diseases.
    6. Diagnostic process and its application to each of these diseases. Includes cytogenetics & immunophenotyping.
    7. Principles of management, prognosis.
  • Lymphoma
    1. The conditions: Non-Hodgkin's lymphoma, Hodgkin's lymphoma, Myeloma.
    2. Biology, Clinical features, classification, investigations, diagnosis, further tests, management & prognosis of the above conditions.
• Diarrhoeal and Inflammatory Disorders
  • General Outcomes for Diarrhoeal and Inflammatory Disorders
    1. Abdominal infections and diarrhoea: prophylaxis and treatment of abdominal sepsis; management of infective diarrhoea (rehydration, isolation, notification, antimicrobials), clostridium difficile
• Bladder Dysfunction and Urinary Tract Infection
  • General Outcomes for Urinary Tract Infection
    1. Management of urinary tract infections: criteria of UTI; different categories of patient; choice of antimicrobial
• HIV Infection
  • General Outcomes for HIV Infection
    1. Describe how widespread HIV is; know what is meant by clades
• CNS Infections
  • Meningitis
    1. Meningitis: blind treatment, flow chart
• Inflammatory Skin Disease
  • General
    1. Cellulitis: organisms and choice of antimicrobial

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