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A proto-oncogene is a gene whose protein product has the capacity to induce cellular transformation buy generic extra super levitra from india what age can erectile dysfunction occur, given it sustains some genetic insult purchase generic extra super levitra from india impotence icd 9. An oncogene is a gene that has sustained some genetic damage and, therefore, produces a protein capable of cellular transformation. The process of activation of proto-oncogenes to oncogenes can include retroviral transduction or retroviral integration (see below), point mutations, insertion mutations, gene amplification, chromosomal translocation and/or protein–protein interactions. Proto-oncogenes can be classified into many different groups, based upon their normal func- tion within cells or based upon sequence homology to other known proteins. Proto-oncogenes have been identified at all levels of the various signal transduction cascades that control cell growth, proliferation and differentiation. Tumour suppressors are so called because cancer ensues as a result of a loss of their normal function; that is, these proteins suppress the ability of cancer to develop. The two most important check points in the eukaryotic cell cycle are the G1 to S transition and the entry into mitosis. When p53 is phosphorylated it is released to carry out its transcriptional activation functions. One target of p53 is the cyclin inhibitor p21Cip1 gene; activation of p21Cip1 effectively leads to stoppage of the cell cycle, either prior to S-phase entry or during S phase. Homozygous loss of p53 is found in 70% of colon cancers, 30–50% of breast cancers and 50% of lung cancers. Mutated p53 is also involved in the pathophysiology of leukaemia, lymphoma, sarcoma and neurogenic tumours. Abnormalities of the p53 gene can be inherited in Li–Fraumeni syndrome, which increases the risk of developing various types of cancers (see Focus on: p53). The only currently known human retroviruses are the human T-cell leukaemia viruses and the related retrovirus (see Chapter 15). This interaction effectively sequesters the cellular proteins away from their normal functional locations within the cell. The predominant types of protein sequestered by viral T antigens have been shown to be of the tumour-suppressor type. It is the loss of their normal suppressor functions that results in cellular transformation. During this process part of the host genome may be incorporated into the viral genome (transduction). Should that host genome include a proliferative gene, the transduced gene will confer a growth advantage to the infected cell. Alternatively, the integration of a retrovirus genome into the host genome (a random process) may place the powerful viral promoter region close to a host gene that encodes a growth-regulating protein. If the protein is expressed at an abnormally elevated level it can result in cellular transformation. For example, the differ- entiation of fingers and toes in a developing human embryo occurs because cells between the fingers apoptose; the result is that the digits are separate. If a cell is unable to undergo apoptosis, it continues to divide and develop into a tumour. For example, infection by papil- lomavirus causes a viral gene to interfere with the cell’s p53 protein; this interference in the apoptotic capability of the cell plays a role in the development of cervical cancer. The process of apoptosis is controlled by a diverse range of cell signals, which may be either extracellular or intracellular. Extracellular signals may include toxins, hormones, growth factors, nitric oxide or cytokines; these must either cross the plasma membrane or transduce to effect a response. The binding of nuclear receptors by glucocorticoids, heat, radiation, nutrient deprivation, viral infection, hypoxia or increased intracellular calcium concentrations can trigger the release of intracellular apoptotic signals by a damaged cell. Caspases (cysteine- aspartic acid proteases) are a family of cysteine proteases, first synthesised as inactive pro- caspases. Eleven caspases have so far been identified in humans, taking one of two forms: the initiator (apical) caspases and the effector (executioner) caspases. Caspases are regulated at a post-translational level, ensuring that they can be rapidly activated. It regulates the cell cycle and thus functions as a tumour suppressor involved in preventing cancer; p53 has been described as ‘the guardian of the genome’. Activation is marked by two major events: first, the half-life of the p53 protein is increased, leading to a rapid accumulation of p53 in stressed cells; second, a conformational change forces p53 to take on an active role as a transcription regulator in these cells. The critical event leading to the activation of p53 is the phosphorylation of its N-terminal domain. The N-terminal transcriptional activation domain contains a large number of phosphorylation sites and can be considered the primary target for protein kinases that transduce stress signals. In unstressed cells, p53 levels are kept low through a continuous degradation of p53. The protein mdm2 binds to p53, preventing its action and transporting it from the nucleus to the cytosol. Also, mdm2 acts as a ubiquitin ligase and covalently attaches ubiquitin to p53, thus marking it for degradation by the proteosome. Increasing the amount of p53, which may initially seem a good way to treat tumours or prevent them from spreading, is in actuality not a usable method of treatment, since it can cause premature aging. Persistent infection causes irreversible changes, leading to carcinoma in situ and eventually invasive cervical cancer. Activating mutations in ras are found in 20–25% of all human tumours, and in up to 90% of specific tumour types. This cascade transmits signals downstream and results in the transcription of genes involved in cell growth and division. Ras is attached to the cell membrane by prenylation; prenylation is the addition of hydrophobic prenyl groups (3-methyl-2-buten-1-yl) to the protein to facilitate its attachment to the cell membrane (forming a ‘lipid anchor’). Mutations in the ras family of proto-oncogenes (comprising H-ras,N-ras and K-ras)are very common. Inappropriate activation of the gene has been shown to play a key role in signal trans- duction, proliferation and malignant transformation. Mutations in a number of different genes, as well as ras itself, can have this effect. Horizontal gene transfer (or lateral gene transfer) is any process in which an organism incorporates genetic material from another organism without being its offspring. Vertical transfer occurs when an organism receives genetic material from its ancestor. Amongst single-celled organisms, horizontal gene transfer may be the dominant form of genetic transfer. The bacterial protein LexA has been identified as playing a key role in the acquisition of bacterial mutations. While such mutations are often lethal to the cell, they can also improve the bacteria’s survival.

To achieve the required uniformity discount 100mg extra super levitra fast delivery erectile dysfunction kolkata, flood correction is either applied during acquisition or post-acquisition 100 mg extra super levitra sale erectile dysfunction pump review. To allow accurate measurement and correction of non-uniformities, the variation per pixel as a result of counting statistics has to be small. Drifts in differential uniformity of more than 1% should be investigated and usually require new uniformity corrections. Uniformity corrections should not be used as a substitute for proper camera tuning and adjustment. A 57Co sheet source with guaranteed uniformity is thus preferred to a fillable flood tank. The procedure described below should be followed: 7 (1) At least 3 × 10 counts should be acquired using a 64 × 64 matrix or 1. As the camera slowly drifts over time, the correction tables have to be updated in order to apply proper correction factors during collection of the image. The exact frequency of reacquiring the correction tables depends on the stability of the camera. In general, energy and on-line uniformity corrections require more frequent updating than linearity correction tables. Energy and uniformity tables are usually obtained by operators, whereas linearity correction tables are typically found by service engineers. While energy and on-line uniformity corrections can in some instances take care of relatively large non- uniformities, these should normally be corrected by a retuning of the camera since they can affect the linearity, resolution and overall sensitivity of the camera. The procedure described below should be followed: (i) Collect correction tables (e. They contain a uniform section for detecting ring artefacts, cold spheres of varying sizes for assessing contrast, and cold and/or hot rods. Subsequent phantom studies are then performed under the same conditions and compared with the reference study to detect changes in performance. Recommended frequency of quality control tests The recommended frequency of quality control tests depends on the particular equipment available and its stability. Significant changes consistently detected between consecutive quality control tests may require the frequency of the tests to be increased. Conversely, the frequency may be reduced if only minor fluctuations are detected over a series of quality control tests. Manufac- turers’ literature may also provide some guidance on the required frequency of tests. An experienced nuclear medicine physicist may in addition provide advice on the frequency for specific tests and equipment. Tests such as those on uniformity are specifically designed to detect malfunction of the equipment and sudden deterioration of performance before they affect a large number of patient studies. Thus the frequency of this type of test should not be reduced even if results remain consistent over a prolonged period of time. The following schedule is thus recommended: Daily: —Visual inspection; —Background and/or contamination; —Photopeak and window setting; —Uniformity. After a major service: —Spatial resolution; —Uniformity with high count flood; —Multiple window spatial registration; —Whole body resolution. When a positron, a positively charged electron, is emitted from a nucleus, it travels a short distance, losing energy until it reaches a resting state. It then interacts with one of the many electrons, whereupon the two annihilate (disappear), giving rise to two 511 keV gamma rays that travel in opposite directions. Detection involves a pair of opposing detectors, which must record events at the same instant of time (i. Firstly, since the two photons travel in opposite directions, the point of annihilation will lie on a straight line joining the points of detection. This means that directional information is determined electronically, without the need for conventional collimation. Collimation may be retained for separate data from different planes; however, within any detection plane no conventional collimation exists. The second important property of dual photon imaging is that for it attenuation is dependent only on the total attenuating path through the patient, but is independent of the exact location of the annihilation event in the tissue. Recent developments have involved removal of these septa, so that there is no collimation within the imaging volume of the scanner, necessitating a 3-D recon- struction of the data. Coincidence circuitry must be added so that the two opposing detectors can detect the two annihilation photons in coincidence, i. It is this coincidence that defines the path along which the photons must have travelled, eliminating the need for a conventional collimator. This introduces problems relating to count rate performance since, for each detected coincidence, there are many more single events (single gamma photons detected without a corresponding coincident event). Several approaches have been implemented to improve the count rate performance of gamma cameras, with some coincidence systems now capable of achieving count rates of several million counts per second. Since for 511 keV photons the stopping power of sodium iodide is relatively poor, manufacturers offer thicker crystals than normal (up to 25 mm thick), with only slightly poorer resolution, due to uncertainty in the location of detected events. The ability to maintain performance is largely attributable to the improved design of recent gamma cameras. It should be recalled that the absence of a collimator means that the resolution is essentially defined by the intrinsic resolution of the gamma camera at 511 keV (typically 4. Dual head systems rotate to different angles around the patient, recording coincidences at each angle. Although the earlier systems did not include attenuation correction, recent systems now have this as an option. Nevertheless, their introduction has resulted in the widespread use of positron emitting tracers in clinical practice. Use of ultrahigh energy collimators A very simple approach to imaging 511 keV photons is to use an ultrahigh energy collimator. Although coincidence imaging was used initially in oncology studies, it has since become evident that only fairly large tumours can be detected. Purchase of dual photon imaging systems All nuclear medicine physicians, assisted by a nuclear medicine physicist, acquire some experience during their careers in purchasing gamma cameras and other accessories for a nuclear medicine service. The decision making process, leading to the purchase of a system performing dual photon imaging, calls for knowledge of the basic physics of coincidence detection and of the differences between 2-D and 3-D acquisition in terms of sensitivity, the ratios between the true and the random events, and scatter fraction, as well as the different methods to overcome these problems. There are a number of different ways to increase the sensitivity of the system and physicians should work closely with a physicist who has extensive knowledge of these areas. It is recommended that they should visit or contact a site that is already functioning. They should also have an opportunity to observe on the workstation the studies performed. The nuclear medicine physicist should be able to review the results of the various quality control tests performed.

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Clinical research bodies licensing medicines buy extra super levitra 100 mg with visa erectile dysfunction doctors augusta ga, international pharma- must therefore continue buy genuine extra super levitra on line impotence herbs, including genetic and bio- ceutical companies, and contract research organiza- technological research, recognizing that the welfare tions. Research fraud distorts the beginning of this chapter are therefore in place, database on which many decisions may be made, there is no such harmonization when it comes to possibly adversely affecting the health of thousands dealing with fraud and misconduct in the context of of others. Indeed, even within Europe there rifyingly dangerous; if licensing decisions were to be is as yet no agreed attitude towards tackling the made based on efficacy and safety data that are problem. Fortunately able aspect of clinical research must be tackled if we there is no strong evidence that such a sequence of are to achieve and maintain confidence in scientific events has yet occurred, but the importance of the integrity and in the clinical research process. Extrapolating this to the rest of the worldÐ trials to determine the thalidomide effect, but had and there is no evidence that the incidence of fraud at least accurately observed its toxicity. It took a decade to data being generated is fraudulent, where investi- demonstrate publicly that such studies did not gators are making up some of the data to be sub- exist, and almost another decade (1996) before mitted to a company andÐworst of allÐmaybe McBride was publicly denouncedÐall of which exploiting their patients in the process. This definition of an eminent public figure whose reputation was includes all of the components of fraud: the such that it was unthinkable that he might be tell- making-up of information that does not exist, and ing lies. Furthermore, this case demonstrates the intending to do so flagrantly in order to deceive messianic complexoccasionally seen in fraudsters, others into believing that the information is true. Adjuvant Breast and Bowel Project, regarding a The first example is that of John Darsee, a re- number of multicenter clinical studies on breast search cardiologist, first at Emory University, then and bowel cancer. He pleaded guilty to 13 counts of commit- have had to be retracted from the prestigious jour- ting `acts derogatory to the honour and dignity of nals in which they first appeared. He was found fraudulent articles have subsequently been re- by an astute pharmaceutical company clinical trial tracted by the editors of the journals in which monitor to have invented some of the laboratory they were published. Indeed, it was worried that it for some time there has been an impression would lose the confidence of doctorsÐand thus amongst pharmaceutical physicians, clinical re- prescriptionsÐif it was seen to be taking such an search associates, and quality assurance profes- action. Sadly, no action followed the publication against the company by banning it from the local of its report (Royal College of Physicians of postgraduate medical center, to which all pharma- London 1991) and it was consequently left to the ceutical companies normally had access for the Association of the British Pharmaceutical Industry sponsoring of meetings. Scientific re- greed (and here it is important to have a recognized search, outside the context of clinical research, is tariff for the involvement of investigators); emo- not subject to any agreed standards, and it is there- tional disturbance or mental illness; and vanity. This is profession throughout most of the world to take generally accepted by pharmaceutical companies as seriously allegations that fraud is occurring. Al- days when clinics would not be expected to be open; ternatively, the doctor may be prosecuted for the and similar handwriting appearing to have been criminal offence of deception. Any sus- police or of the Crown Prosecution Service where a picion raised by a monitor justifies consideration criminal offence may have been committed. The partner discovered a number of who, during 1995, claimed to have performed a consent forms that were not signed by the patients pioneering operation, when a subsequent enquiry in question, and who were not aware of their in- found that he had not done so. Furthermore, the prac- transplanted successfully an ectopic pregnancy and tice nurse was required to alter the dates printed by achieved a successful full-term vaginal delivery. Second, both these reports were published in ician in Edinburgh who, in his time, had been the British Journal of Obstetrics and Gynaecology; Secretary of the Royal College of Physicians of the article on relocation of the ectopic pregnancy Edinburgh (Dyer, 1997). Furthermore, Cham- echocardiography data had been discontinued by berlain was Editor of the journal in question and the laboratories concerned some 6 months prior to President of the Royal College of Obstetricians and a particular study having been commenced. Obviously, Chamberlain could led to the involvement of an investigational agency, have had no part in the non-existent operation, which conducted further enquiries, including the and his co-authorship was thus untenable. He sub- questioning of a number of patients, whose consent sequently resigned both his editorship and his presi- to be so questioned had been obtained by the local dency. These enquiries revealed that conducting these false activities for financial gain; Dr Anderton had not obtained consent from a his case demonstrates the objective of some fraud- number of patients for their involvement in a clin- sters, who are usually very vain, of wishing to be ical trial and, worse, that he had required his per- seen to be pioneers. In both cases Exclusion Agreement, in which he agreed to exclude the fraud discovered was multiple, and on a very himself from publicly funded research activity for a extensive scale, where the doctor involved had gone period of 3 years (Anon, 1997b). Only the utmost vigor in applying this ciences, the possibility of fraud occurring must be policy will be successful, but it is in the ultimate clearly recognized by those whose responsibility it interests of patient safety that this happens. Cases recently submitted by the industry have nearly all refers, the monitoring process, how suspicions were first raised, provided sufficient evidence for this stage to be unnecessary. If it appears to the President that the evidence and witnesses to rebut the allegations, to call attention matter is trivial, or irrelevant to the question of serious profes- to any mitigating circumstances, and to produce testimonials or sional misconduct, he/she will normally decide that it shall pro- other evidence as to character. If the doctor considered by the Professional Conduct Committee (Anon, responds to this invitation, the explanation offered, which may 1988; Andersen et al, 1992; Smith, 1997; Lock, 1989). If the include evidence in answer to the allegations, is placed before the facts alleged are found by the Committee to have been proved, Preliminary Proceedings Committee that next considers the then it is up to the Committee to determine whether, in relation case. Committee that the doctor may be suffering from a physical or mental illness that seriously impairs his/her fitness to practise, Doctors who are suspended or erased have 28 days in which to the Committee may refer the case to the Health Committee give notice of appeal against the direction to the Judicial Com- instead of to the Professional Conduct Committee. To date, about half The rules governing the operation of the Professional Con- have been erased from the register, and the rest have received duct Committee require that any allegation of serious profes- lesser disciplinary punishment. With multinational corporation has to deal with many respect to the multinational pharmaceutical cor- societal cultures, even, sometimes, within a single poration, culture can be thought of at three levels: nation. Sensitivity to cultural considerations will One can apply the concepts in this table to the help identify, conceive, present, and respond to pharmaceutical industry, e. Well-regulated goals are most important goal is continuity through continuity of group time relationships through time is not critical Modified from Kluckhohn and Strodtbeck (1961). Despite the calls for cultural convergence in medi- Group goals are emphasized by those who see a cine, there are major differences in the incidence lineal relationship of man to man as important. Concern for the welfare of the extended drug reactions to a standard therapy varies dramat- family might result in the hiring of a close relative ically from country to country. Aspects of medical culture of particular importance to the Corporate Culture pharmaceutical industry are those affecting drug development, approval, and marketing, including The principal concern of the multinational corpor- those that may determine whether a drug should ation is the extent to which corporate culture con- have prescription or over-the-counter status. An example of a strong corporate culture currently under way in the area of drug develop- that crosses business and geographical boundaries ment and regulatory approval, under the auspices is that of Procter and Gamble. The various cost-cutting ap- leadership that is responsive to potential conflict proaches have included: arising in multinational operations from cultural diversity. In each country Culture Culture where the two multinationals collaborate, there is a Corporate Cultural need to reconcile their corporate cultures, whilst Responsiveness simultaneously being responsive to local societal and medical cultural considerations. Languages Corporate Culture A multinational corporation necessarily conducts its business in many different languages, presenting challenges of internal and external communica- Figure 39. Companies with a weak corporate culture turally appropriate behavior are paradoxically more likely to cause local ten- sions by insisting on a rigid mode of operation. Companies with a strong corporate culture are decentralizationÐthis will depend upon many more likely to operate according to local cultural other considerations (e. However, it facilitates an appropriate devolution of managerial power, which might otherwise be difficult or even Societal, Medical and Corporate Culture impossible. The challenge to the multinational cor- poration, therefore, is to have a strong corporate Interplay culture that is compatible with diverse societal and Figure 39. A locally responsive cor- iety of stages, even before the first human studies, porate culture favors neither centralization nor to reduce some of the uncertainties of the process. Some countries require brief summar- notes for guidance, with a 6 month consultation ies of available information, while others require period, on (a) non-clinical safety studies for the detailed information on the preclinical, pharmacy, conduct of human clinical trials for pharmaceut- chemistry, and other clinical data to be submitted.

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Topics assessed with three written knowledge tests buy generic extra super levitra on-line statistics of erectile dysfunction in us, as include the defnition of primates extra super levitra 100 mg low price jack3d causes erectile dysfunction, archaic primates, well as participation in lab, lab presentations, and the frst modern primates, oligocene primates and team-based learning. This approach, otherwise An integrated coverage of functional anatomy known as the phylogenetic systematics, includes including cadaveric dissection, clinical and basic discussions of homology, the hierachy of evolution- science lectures, discussion groups and clinical ary common descent, parsimony, and computer correlation sessions. A research question or topic is chosen, lution of Mesozoic Ornithodira including dinosaurs, appropriate data are collected, analysis is done and stressing their comparative and functional anatomy, a report is written. A com- This course will consist of discussions of readings bination of lectures, discussion, and projects will in both the theory and application of allometry to give the students applied knowledge of these tech- various zoological issues. Different types of data will be discussed, both “classical” sources as well as more recent including landmark coordinate data, outlines, and articles dealing with this general topic. The theory underlying different analytical approaches will be described and discussed. Students will gain knowledge of the functional and evolutionary anatomy of vertebrates. Subinternship in Gynecology and Obstet- Prerequisite:Completion of Ob/Gyn Core Clerkship. Specifc times during the This clinical experience consists of a subinternship year; 3 or 4 weeks. Basic research and development involving This course provides a framework for understand- the application of informatics to a variety of ing decision support in the workfow of the health medical and basic science disciplines is also sciences. The focus is on the types of support being carried out by individual members of needed by different decision makers, and the fea- the division, and the results of these efforts tures associated with those types of support. A are being applied to research and education- variety of decision support algorithms is discussed, al initiatives throughout the Johns Hopkins examining advantages and disadvantages of each, with a strong emphasis on decision analysis as the Medical Institutions. Students are include: medical informatics, genome infor- expected to demonstrate facility with one algorithm matics, information management, consumer in particular through the creation of a working proto- health informatics, computer based docu- type, and to articulate the evidence for effcacy and mentation systems for point of care, informat- effectiveness of various types of decision support ics and evidence based medicine, biomedical in health sciences and practice, in general. The service component of the division is the Security of health information is a central com- Welch Medical Library. In addition to provid- ponent of any information system in the health ing access to the published literature (printed sciences. This course will address the security and electronic) and numerous scientifc data- technologies, the confdentiality polices, and the bases, the Welch Library offers educational privacy responsibilities in providing clinical care and outreach programs to assist clinical and (e. Specifc domains will be used to ing to develop core competencies needed for an exemplify the underlying theoretical principles and informationist role in the felds of clinical medi- issues and may include several of the following, cine and public health. A combination of lecture and laboratory the identifed evidence; and effectively presenting exercises will teach the skills involved in fnding, analyzing, and delivering evidence for clinical and that evidence. Evaluations will be based on partici- public health decision-making: identifying a ques- pation in class, exercise completion, and fnal oral tion embedded in a case presentation; developing and written presentations of assigned cases. McGehee medical as the result of Western policital-economic Harvey Chair in the Department of the History and institutional structures, cultural values, and the of Medicine rise and complexities of “scientifc medicine”. This course examines the long history of disease * Faculty, School of Arts and Sciences. Emphasis is on history of medicine and kindred sciences, the ways in which political, social, and economic institutions and practices infuence the history of including the history of public health. Interviewing is a powerful technique that should History of Medicine be in the toolkit of almost any historian working the Independent study program on a topic to middle of late twentieth century. In this seminar, be agreed upon with appropriate faculty you will be introduced to the range of techniques member. This seminar-style course is intended for students How do metaphors in science, technology, and in the basic sciences and in the history of science medicine originate and how do they infuence and medicine. The course explores such exam- twentieth-century physiology, immunology, genet- ples as William Harvey’s analogy between the heart ics, and neuroscience using both original research and a pump, Charles Darwin’s concepts of the papers and historians’ accounts. Themes under struggle for existence and natural selection, military discussion will include theory and experiment, metaphors in the history of public health, the use of styles of research, ethics of experimental work and metaphors of production in medicine, and the com- scientifc publishing, and the impact of social inter- parison of the brain to a computer. This course will examine the impact of colonial and For doctoral candidates and other advanced stu- post-colonial development on patterns of sickness, dents engaged in original research under faculty health, and health care in Africa. What were the range of responses from will explore the various economic and political inter- religious to therapeutic to disease in China? What ests, as well as the cultural assumptions, that have are Chinese acupuncture, moxibustion, and herbal shaped the development of ideas and practices medicine? Who practiced medicine in China; what associated with international health in “developing” did they practice; and how do we know what we countries. Third, their attention is direct- Professor of International Health ed to the patient as a problem, and they are R. They record their refections and structured cine will be assigned to a preceptor who will patient exercises in an online Learning Portfolio. It is particularly small group discussions and further instruction in clinical skills with their college faculty. To ft the interests They are assessed by their preceptors and with and ability of the student, considerable fex- structured observation of clinical skills in the Simu- ibility in the choice of elective program will be lation Center, as well as for their written work and a possible. After completing the An interdepartmental course in the clinical tech- four week course, students will be able to describe niques of patient evaluation. Students working in the factors that render microorganisms virulent and small groups with an instructor from the clinical correlate these factors with disease processes. A differential diagnosis is of infectious diseases and understand how indi- formed. Whereas the major instruction is from Inter- vidual variability impacts manifestations observed nal Medicine, also included is instruction given by on a population level. Students spend This course is a prerequisite for all clinical clerk- 1-2 afternoons per week, usually working in groups ships and ordinarily will be taken between the third of 5 with their college advisor, to learn and gain and fourth quarters of the second year. Its purpose confdence with best practices in doctor-patient is to prepare new clerks for the daily activities of communication, how to obtain, organize, and com- patient care. Through a combination of lectures, municate to colleagues a patient’s medical history, laboratory exercises and small group discussions, and how to perform a multi-system physical exami- students will learn practical aspects of relating to nation. Students will be prepared for participation patients and their families; to provide care accord- in the Longitudinal Clerkship beginning in January ing to diagnostic probabilities and relative priorities; of Year 1. Resources to assist students in learn- to recognize and manage common acute problems; ing include volunteer outpatients, standardized and to order, perform and interpret the results of patients, trained physical exam teaching associ- basic laboratory tests. Medicine—Second, Third and Fourth The small group format provides students with Years multiple opportunities to learn and practice these This required clinical course is repeated each quar- important skills in a safe environment, enriched by detailed feedback, and supplemental practice ses- ter of the academic year and in the summer. Prerequisite for admission is satisfactory comple- The goal of the Longitudinal Clerkship is to inte- tion of the frst two years of the curriculum at Johns grate the learning of basic science and clinical sci- Hopkins School of Medicine. Available four quarters weeks on the medical service of The Johns Hop- and summer (except July). On most of medical decision making and treatment with the these services students work under the supervision assistance of the housestaff team. Students partici- and tutelage of interns, residents, and the admitting pate in teaching attending rounds, house staff work physician.

S. Asam. University of Texas of the Permian Basin. 2019.

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