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

Lecture: Antibiotics

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
5. Understand the principles of prescribing
6. Give examples of antimicrobial side effects and interactions

Lecture: Management of Common Infections

1. Things to consider when treating an infection:
2. Where to go for information (BNF) and advice
3. Management of urinary tract infections: criteria of UTI; different categories of patient; choice of antimicrobial
4. Cellulitis: organisms and choice of antimicrobial
5. Meningitis: blind treatment, flow chart
6. Abdominal infections and diarrhoea: prophylaxis and treatment of abdominal sepsis; management of infective diarrhoea (rehydration, isolation, notification, antimicrobials), clostridium difficile
7. Guidelines and policies for antimicrobial prescribing in general
8. Pneumonia: severity (CURB-65 score), guidelines, choice of antimicrobials
9. Infective endocarditis: organisms, valves, guidelines for choosing antimicrobial

Lecture: FUO

1. Understand what is meant by the term PUO and know the common causes of this
2. Know the common causes of fever in the returning traveller and how to diagnosis these conditions
3. Understand the importance of isolating patients with PUO in whom an infective aetiology is thought likely
4. Know that you should inform the laboratory if you are wish to send high risk samples to them
5. Know where to obtain specialist help both for travel advice for patients and for the management of people returning from their travels with undiagnosed fever

Lecture: Fever in the Returning Traveller

1. Travel history, vaccination history, prophylaxis history
2. Preventative measures
3. Investigation scheme
4. Features & treatment of malaria
5. Features & treatment of typhoid & paratyphoid fever, dengue, Chikungunya, rickettsial fevers, Amoebic liver abscess, Brucellosis, viral haemorrhagic fevers, tetanus, diphtheria
6. Differential diagnosis in fever & respiratory disease, fever & jaundice, fever with hepatosplenomegaly, fever & eosinophilia, fever & gastrointestinal symptoms
7. Protection of staff, & notification

Lecture: 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 how widespread HIV is; know what is meant by clades
6. Describe Human Endogenous Retroviruses

Lecture: Prescribing and Therapeutics in Year 3 and Beyond

1. Gain more awareness of prescribing errors
2. Become aware of learning opportunities in Therapeutics throughout year 3
3. Gain insight into structure and knowledge areas of the Prescribing Safety Assessment

Lecture: Learning and Assessment of Safe Prescribing

Lecture: Dosing Calculations

1. Understand unit conversion and be able to express percentage concentrations
2. Calculate weight-related doses
3. Calculate IV flow rates for drug infusions
4. Manage the above through a series of worked examples

Lectures: Safe Prescribing: Information Sources & Avoiding Errors

1. Interpret drug dosing information in the BNF
2. Identify how to use the BNF to access information about drug treatments
3. State the difference between formulations of medicine
4. Identify other sources of information about drugs
5. List the common causes of prescribing errors
6. Be aware of recent prescribing errors that have occurred in NHS trusts

Lecture: Safe Prescribing: History & Reconciliation

1. Define and identify the steps involved in Drug reconciliation
2. Define in which patients this is needed and where it should be documented
3. Know how to record Allergy status
4. Understand the risks involved after seeing a video of a medication incident

Lecture: Haemostasis 1

1. List key components of haemostasis: vessel wall, platelets, Von Willebrand factor, coagulation system.
2. List platelet functional components: molecules, cell membrane, organelles.
3. Describe the function of Von Willebrand factor.
4. List the events in primary & secondary haemostasis
5. List inherited platelet diseases, Von Willebrand's disease & anti-platelet drugs.
6. Describe the coagulation pathways, with the role of tissue factor & all the factors.
7. Describe the coagulation tests.
8. Describe haemophilia, & dental care.
9. Describe fibrinolysis.
10. Describe the drugs that affect coagulation.

Lecture: Antiviral Drugs

1. List the stages in the viral replication cycle from virus entry into the cell to virus release
2. List the phases of the HIV replication cycle that can be inhibited by drug treatment
3. List the drugs that can inhibit each stage of the viral life cycle
4. List the stages of the influenza life cycle that can be inhibited by drugs and the drugs concerned
5. List the drugs currently used for treatment of Hepatitis C
6. List the approaches to Hepatitis C therapy currently being developed

Lecture: Adverse Drug Reactions.

1. Define adverse drug reactions (ADRs)
2. Appreciate the importance of ADRs
3. Recognise ways to classify ADRs
4. Understand how to minimise ADRs
5. Recall common examples of ADRs

Lecture: Therapeutic Drug Monitoring 1

1. Demonstrate the ability to appropriately adjust dosage regimens by the use of therapeutic drug monitoring
2. 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
3. Know that other drugs that may also require therapeutic drug monitoring e.g. Ciclosporin, lithium
4. Know the impact of pharmacogenetics on drug dosing, give examples
5. Understand the rationale of therapeutic drug monitoring as a guide to therapy and outline areas where it is useful

Lecture: Drug Interactions

1. Define and distinguish between pharmacodynamic and pharmacokinetic interactions
2. Be able to describe different forms of pharmacokinetic interaction: absorption/distribution/metabolism/excretion
3. Understand that drug interactions are mostly unwanted and increase patient risk although some are beneficial
4. Be able to use the BNF to look up drug interactions information

Lecture: Rare Bleeding Disorders

1. Describe the frequency, presentation, significance & treatment of: Factor XI, VII, V, X, II (prothrombin) deficiency, Factor XIII & fibrinogen, Combined V&VIII, Vit K dep factors deficiency; & Severe platelet disorders –Glanzmanns –Bernard-Soulier
2. Consider education, travel insurance, dental care, family screening, genetic counselling, consanguinity, hepatitis vaccination

Lecture: Drugs & the Genome

1. Be able to describe the main approaches and tools used to identify genes for common disease and drug response and safety
2. Be able to give some examples of where genetic makeup affects drug effectiveness and safety; understand how this may contribute to drug discover
3. Understand some of the ethical issues around genetic data and potential risks to the individual

Lecture: Drugs of Misuse

1. Collate the features that make up the toxidromes of: Serotoninergic drugs; Opiates; Sedatives
2. Know when to use specific antidotes and treatments in the management of drugs of misuse
3. Be able to list organ systems that are affected by long-term use of alcohol and cannabis

Lecture: Evidence-based Prescribing

1. Describe the levels of evidence and recommendations for drug therapeutic strategies
2. Explain the harm:benefit ratio
3. Define the following: Randomised trial; double blind; multi-centre; placebo-controlled; cohort study; case control study; systematic review/meta-analysis; case-series; phase I-IV trials

Lecture: Prescribing IV fluids

1. State the distribution of fluids in a healthy subject
2. State the contents of commonly prescribed fluids
3. State the daily fluid / electrolyte requirements of a healthy 70kg subject
4. State symptoms and signs consistent with fluid depletion / overload
5. State potential adverse events related to intravenous fluid therapy
6. Recognise situations where fluid therapy differs from a healthy subject
7. Formulate an appropriate intravenous fluid prescription

Lecture: Prescribing by Different Routes

1. Describe rationale for the different drug administration routes
2. Provide examples for the different routes

Workshop: Death, Dying & Bereavement

1. Outline current trends in life expectancy
2. Review definitions and experiences of dying including the 'good death'
3. Examine different dying trajectories and the role of medicine in contemporary dying
4. Demonstrate an understanding of the processes involved in normal grief and bereavement
5. Discuss experiences of health professionals working with dying patients and relatives

Lecture: End of Life Ethics

1. Give arguments for and against hastening death of patients in various circumstances
2. Outline the duties and prerogatives of doctors and the rights of competent patients in relation to the hastening of death and specify the circumstances where they apply
3. Outline the difference between various forms of hastening death and distinguish between the ethico-legally acceptable ones from those which are unacceptable
4. Specify the provisions of acceptable Advance Directives, action based on the rule of double effect, DNAR orders, withdrawal of life-saving treatment and non-treatment decisions
5. Explain the role of relatives in relation to withdrawal of treatment in incompetent adults

Lectures: Hospital Infections

1. Infection control at Barts health: hand hygiene, environment, device management.
2. Measures to control hospital infections.
3. High impact interventions.
4. Hand hygiene measures: details.
5. Personal protective equipment.
6. Isolation - Who? How?
7. Environment. Likely sites of VRE.
8. MRSA, Clostridium difficile, Tuberculosis: prevention of spread.
9. Sharps injuries, vascular access device care, catheter care

Lecture: 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.

Lecture: 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.

Lecture: Myeloproliferative Syndromes

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.

Lecture: Pharmacodynamics

1. Appreciate different types of drug receptor
2. Define and contrast the following terms: affinity, selectivity, specificity, agonism, partial agonism, inverse agonism, competitive and non-competitive antagonism, allosteric modulation, efficacy, potency
3. Be aware of the differences in pharmacodynamics between small chemicals and biological therapies

Lecture: Pharmacokinetics

1. Define and describe clinical importance of liberation, absorption, distribution, metabolism and excretion
2. Distinguish between and describe clinical importance of zero and first order kinetics; half life, clearance and volume of distribution
3. Be aware of the differences in pharmacokinetics between small chemicals and biological therapies

HSPH Workshop 3: Lifestyle and Disease - Advising Patients on Obesity

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.

Genetics 3: Complex Gene Traits

1. To be able to define the differences between monogenic and complex genetic diseases
2. 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
3. To know some examples of complex gene traits where new genes have been mapped and what has been found and why it is important

Genetics 2: Single Gene Disorder

1. What? The type of alteration of genetic material: molecular and cytogenetic, and subdivisions.
2. How? (type of molecular biological consequence)
3. Where? (which cells are affected)
4. Who? (patterns of inheritance)
5. When? (at what point is the disease visible)
6. 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
7. Gene therapy: the characteristics of a particular genetic disease that render gene therapy likely or unlikely to be successful.

Lecture: 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

Lecture: Genetics of Autoimmunity

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

Lecture: Prescribing in Disease (CKD/CLD)

1. Understand how liver and renal disease alters pharmacokinetics of drugs
2. Know different methods of assessment of liver and renal disease and be able to critique strengths/weaknesses of them
3. Be aware of the roles of the liver and kidneys in drug metabolism and elimination
4. Identify commonly prescribed drugs that alter liver metabolism of drugs and understand the consequences of this alteration
5. Identify common drugs that need dose adjustment in chronic liver and renal disease
6. Understand different patterns of drug-induced injury to hepatic and renal systems and list some common examples of drugs that cause them
7. Know where to find information to guide safe therapeutic decisions in chronic liver and renal disease

Lecture: HLA

1. Be able to draw a simplified map of HLA region
2. Distinguish between the class I & class II loci
3. Understand the function of the HLA molecules
4. Understand the meaning of 'linkage disequilibrium'

Lecture: Ethical & Legal Issues Concerning Patient Privacy and Confidentiality

1. Explain the moral and professional foundations of the duty of confidentiality.
2. Recognise the importance of confidentiality in research, clinical practice and publication.
3. Describe situations where the duty of confidentiality can or ought to be relaxed.
4. Outline fundamentals of good practice concerning management of confidential information.
5. Outline good ethico-legal practice in the use of photography for clinical, teaching and research purposes.

Lecture: Autoimmune Disease

1. Review of mechanisms of tolerance induction
2. A classical animal experiment
3. “Autoimmune” diseases: what is it, how many?
4. Differing roles of autoimmunity
5. Genetics, infection, cancer & autoimmunity
6. Thumbnail sketches of different diseases

Lecture: Transplantation

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.

HSPH Workshop: 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.

Lecture: Clinical Toxicology

1. To summarise the general management of poisoned patients
2. To be able to select the specific management of common poisonings: Aspirin; TCAs; Paracetamol; Beta-blockers

Lecture: Ethical and Legal Issues in Prescribing

1. Define the 10 principles of safe prescribing
2. Gain awareness of ethical and legal aspects related to prescribing

Lecture: Justice and Allocation of Resources within the NHS

1. Explain the concepts of justice and distributive justice
2. Recognise indicators of scarcity within the NHS and provide competing explanations of the sources of this scarcity
3. Describe different ethical approaches to distributive justice and allocation of resources
4. Outline morally acceptable approaches to the allocation of resources within the NHS
5. Give arguments for and against patients paying for their own health care if their condition has been a direct result of their lifestyle

Immunology 4: The Allergic Lung

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

Immunology 3: Innate Immunity and Priming of T&B Cell Responses

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
2. 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)
3. State how phagocytes move and kill (together with defects), and state the structures and molecules that they interact with: endothelial cells, adhesion molecules, matrix
4. 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
5. Distinguish between Th1 and Th2 responses and list the cytokines involved in each stating the cells that secrete them
6. Delineate the mechanism of septic shock

Immunology 2: Immunodeficiency

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. 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.
5. List the features of the following secondary immunodeficiency syndromes: neutropenia, Chronic lymphocytic leukaemia, splenectomy, AIDS, Immunodeficiency due to immunosuppression.

Immunology 1: 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
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. 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

Ethics Workshop 2: 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)

Ethics Workshop 4: 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

Ethics Workshop 5: Fitness to Drive

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

Ethics Workshop 1: Truth Telling

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

Infection 3: Bacterial Infections in the Immunocompromised

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.

Infection 4: Viral Infections in the Immunocompromised

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