This form of change is seen in those ingesting more than 80 g alcohol per day (6 units generic 20mg cialis sublingual with visa, 1 bottle of wine or 3 pints of beer) purchase cialis sublingual 20mg on line. Steatosis r Cirrhosis: Repeated damage has led to fibrosis, with damage to the normal architecture upon which func- Steatohepatitis tion is dependent. Up to 10% of patients with cirrhosis, secondary to Cirrhosis alcohol use, develop hepatocellular carcinoma. Ultra- sound may show significant cholestasis and be mistaken liver injury, occurring in patients with little or no his- for extra-hepatic obstructive jaundice. In late stages patients ranges from fat accumulation in hepatocytes (hepatic maybeconsideredforlivertransplantiftheyhaveproved steatosis) to hepatic steatosis with hepatic inflamma- abstinence. The pathogenesis of nonalcoholic fatty liver disease is r Fatty liver is reversible, with complete recovery. However, if they abstain from drinking 90% acid entering the liver, decreased free fatty acid leav- have a full recovery. Insulin resistance appears to be important in the acute episode of hepatitis have the poorest prognosis development of hepatic steatosis and steatohepatitis. Chapter 5: Disorders of the liver 207 Clinical features Drug-induced liver disease Most patients are asymptomatic, fatigue, malaise and Hepatic injury caused by drugs accounts for 2–5% of rightupper abdominal discomfort may occur in some hospital admissions for jaundice. Hepatomegaly is a frequent find- atotoxicity may be subdivided into predictable (dose- ing. Most cases are found on incidental abnormal liver dependent) and idiosyncratic, although more than one function tests. Patients who develop cirrhosis may be at increased risk for hepatocellular carcinoma. Ultrasound r Idiosyncratic hepatotoxins appear to cause a chronic scan may indicate fatty infiltration. Management The pathophysiology of drug hepatotoxicity may also be r Obesity, hyperlipidemia and diabetes should be man- divided into the liver pathology caused (see Table 5. Definition r In the few patients who progress to end stage, liver Achronic hepatitis of unknown aetiology characterised failure transplantation may be required; however, re- by circulatingautoantibodiesandinflammatorychanges currence in the transplanted liver has been reported. Intrinsic Idiosyncratic hepatotoxins hepatotoxins Predictable Idiosyncratic Dose-dependent Dose-independent Common Rare Direct Indirect Hypersensitivity Abnormal (‘autoimmune’) metabolism Figure 5. Patients may have an acute hepatitis or complica- drugs tions of cirrhosis such as portal hypertension (e. In pa- steroids, azathioprine, cytotoxic tients who develop end stage liver disease despite med- drugs, alternative medicine such as ical treatment liver transplantation may be considered Bush Tea Liver tumours Oral contraceptive steroids, although hepatitis may recur in the transplanted organ. The risk of hepatocellular carcinoma is low, in contrast to chronic Prevalence active hepatitis due to viral causes. No autoimmune mechanism has yet been proven, al- though high titres of autoantibodies are characteristic. Sex Patients may have features that overlap with primary >90% female biliary cirrhosis and primary sclerosing cholangitis. Au- toimmune chronic hepatitis is also commonly associ- Aetiology ated with other autoimmune disorders e. Antibodies to mitochondria are diabetes mellitus, thyroiditis and ulcerative colitis (more present; however, their exact role in pathogenesis often associated with primary sclerosing cholangitis). Chapter 5: Disorders of the liver 209 Environmental triggers suggested include enterobacte- ducts. Pathophysiology Management Chronic inflammation of the small intrahepatic bile Supportive treatment involves ursodeoxycholic acid ducts leads to cholestasis and destruction of bile ducts. Duct plementation, management of complications such as epithelium in the pancreas, salivary and lacrimal glands varices, hyperlipidaemia. Pa- Asymptomatic patients may have a normal life ex- tients may complain of fatigue and pruritus, followed pectancy. Any sign of liver disease atomegaly, high bilirubin, low albumin and cirrhosis may be present, such as clubbing, hepatomegaly, spider correlate with shortened survival (5–7 years in severe naevi, xanthomata. Definition Macroscopy/microscopy A disease of unknown aetiology in which chronic in- Throughout the disease, copper accumulates due to the flammation of the bile ducts leads to stricture formation chronic cholestasis. There is also a strong association with inflam- Complications matory bowel disease, which is present in 60–75%, but r Oesophagealvarices,osteoporosis,osteomalacia,pan- may be asymptomatic. Chronic inflammation of the intra- and extra-hepatic r Associated with many other disorders, such as bile ducts leads to fibrosis and short strictures form Sjogren’s,¨ hypothyroidism, systemic lupus erythe- which obstruct the passage of bile.

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    Key: b Ref: Cholestatic Jaundice (Page 946) Davidson’s Principles and Practice of Medicine generic cialis sublingual 20 mg on line. A patient presents with history of intermittent fever discount 20 mg cialis sublingual mastercard, abdominal pain and headache. Key: b Ref: Antimalarials (Page 211) Davidson’s Principles and Practice of Medicine. When such a science is applied to a dynamic human being that is being continuously run with food – Thiruvalluvar, The Kural 1072. Human When one enters the medical college the first thing that body is not only non-linear,it follows the holistic rules of happens is that the person is made to forget his/her the universe. All these make the present the present educational system; even as early as entry to medical science a square plug in a round hole. In the practice of bedside medicine, progress and if we want to progress in medical science however, common sense is not just common but it is we have to think deeply of changing our mind set and commoner than what one thinks it is. The statistical science follow the new science of chaos-of non-linearity and of medicine can, at best, manage to size up cohorts of holism. It is basically status quoists wanting the comfort of the existing the past experience of the doctor with his clinical acumen order. We are usually afraid of change and what it might that helps him at that point in time. But life itself is ceaseless change till decision one way or the other based on his own death. Unfortunately, that is what medicine, sold as the gold standard in medical research, is presumed in the science of medicine. The British claim The art of medicine is the one that makes the patient’s that it was Archie Cochrane that introduced the term and day. No amount of science and technology will ever be they claim that the first such study was undertaken by able to replace that humane human being, the doctor their Medical Research Council in 1940 of the role of that alone could put to rest the universal anxiety that is streptomycin in tuberculosis and on the role of the part of all illnesses since every disease presents through whooping cough vaccine. In reality even mathematics randomisation so that precisely framed questions can be becomes shaky. Randomised Controlled removed from reality and when it is closer to reality it is Clinical Trials. However, in our enthusiasm, we have and after modern medicine do not show much to write extrapolated those designs for the study of treatment of home about, either! David When one has a control population the same must be Eddy of Stanford University, a cardiac surgeon turned identical to the study cohort for the results to be reliable. To cap it, we research, has invented a new soft ware tool that has can only measure a few phenotypic features of both the thousands of differential equations to test the efficacy of groups for comparison. These, by any stretch of what we do in medical science arena in a virtual field, named imagination, could be taken to match the two groups. That would shake the whole edifice of plots-Kuwait Medical Journal)) The Whole Person Healing medical science as the foundation is built only with dry Group, a collection of humane scientists lead by Prof. How does randomisation compensate for our lack Rustom Roy, the father of nano-technology, a distinguished of knowledge of the whole of the initial state of the human professor at the Penn. State University, based in Washington organism in the study is something that has no answer. Be that as it may, modern medicine could, at best, reach only a minority in this world. Large sections of the The linear thinking in medical sciences with the population live without the benefit of modern medicine. Time has come to think of good alternatives for which not close our eyes to the possibility that there could be there is no dearth. We only have to change our attitude to authentic methods in other systems as well that might those methods and we could always use our modern help us unravel the mystery. Our ostrich like attitude denies scientific methods to evaluate their efficacy and then the ardent student in the medical school even a remote accept or reject rather than prejudging their capacity. One could argue that only modern my long experience it is the young student in the medical medicine is scientific and the rest is mumbo-jumbo. Then school, given the freedom to think, that would come up modern medicine’s audit should show that. The per capita death rate of the students are our best stimulators provided both of us grievously injured in the Vietnam War, where hi-tech remain humble and open to correction. Many effective modern medicine was at hand in Saigon, was slightly worse systems of health care have been in existence for “times than the results of Falkland’s War, where the British did not out of mind” in this world long before the “so called” Journal, Indian Academy of Clinical Medicine?

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    Physicians’ use of computer software in Should we confirm our clinical diagnostic certainty by autopsies? Diagnostic yield of the autopsy in a university hospital and a patient information during clinical care buy cialis sublingual 20 mg. Rationality in medical decision making: a ical guidelines: are there any ”magic bullets”? Premature conclusions in based guidelines on management of asthma and angina in adults in diagnostic reasoning buy cialis sublingual 20 mg on line. The epistemology of clinical reasoning: perspectives education activities change physician behavior or health care out- from philosophy, psychology, and neuroscience. Medical diagnostic decision support systems—past, Perceived causes of family physicians’ errors. A report card on computer-assisted diagnosis—the among high-risk specialist physicians in a volatile malpractice envi- grade: C. Billions for defense: the pervasive nature of defensive tics on perceptions of decision support systems. February 22, 2006 [published correction appears in The New cognitive model and empirical findings. A randomised public- potential impact of a reminder system on the reduction of diagnostic health trial on automation-assisted screening for cervical cancer in errors: a quasi-experimental study. Measuring the impact of diagnostic decision support on the quality of clinical decision mak- J Med. Learning from mistakes: factors that influence how students and J Am Med Inform Assoc. Effects of computerized physician order entry on prescribing medicine: what’s the goal? Training to improve calibration and discrimina- tion: the effects of performance and environment feedback. February 13, smears: how frequently are ”abnormal” cells detected in retrospective 2006:96–107. Overconfi- evolved to deal with 10,000 specific illnesses, all of which dence is one of the most significant of these biases. In both Effective problem solving, sound judgment, and well-cali- arenas, the first presentation of the illness is at its most brated clinical decision making are considered to be among undifferentiated. Alternately, the general this important area has been actively researched for only domain where the diagnosis probably lies is identified and about 35 years. The main epistemological issues in clinical the patient is referred for further evaluation. Much current work uncertainty progressively decreases during the evaluative in cognitive science suggests that the brain utilizes 2 sub- process. By the time the patient is in the hands of subspe- systems for thinking, knowing, and information processing: cialists, most of the uncertainty is removed. Their characteristics are listed in say that complete assurance ever prevails; in some areas 9 13 Table 1, adapted from Hammond and Stanovich. The system is fast, asso- For the purposes of the present discussion, we can make ciative, inductive, frugal, and often primed by an affective a broad division of medicine into 2 categories: one that component. Importantly, our first reactions to any situation deals with most of the uncertainty about diagnosis (e. These settings, therefore, deserve the closest scru- 13 situation (Table 2), and providing further characterization tiny. To examine this further, we need to look at the deci- of System 1 decision making. It encompasses processes of emotional regulation and implicit Statement of Author Disclosures: Please see the Author Disclosures 15 learning. Automaticity High Low The essential characteristic of this “nonanalytic” reason- Rate Fast Slow ing is that it is a process of matching the new situation to 1 Reliability Low High 18 of many exemplars in memory, which are apparently Errors Normative Few but distribution significant retrievable rapidly and effortlessly. As a consequence, it Effort Low High may require no more mental effort for a clinician to recog- Predictive power Low High nize that the current patient is having a heart attack than it Emotional valence High Low is for a child to recognize that a dog is a four-legged beast.

    Previous work A great deal of work has already been done to defne curriculum-level outcomes/ competences for medical education purchase cialis sublingual 20mg without prescription. Many other national and institutional outcomes frameworks have been developed in Europe and elsewhere cialis sublingual 20 mg without a prescription. 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. Tuning methodology specifes an opinion survey, to include academics, graduates and employers, who are asked to rate learning outcomes in terms of their importance for graduates. These rankings inform the formulation of the fnal outcomes framework by the Task Force. For Tuning (Medicine), a detailed questionnaire was created using an online survey instrument (www. The survey asked respondents to rate 115 learning outcomes as essential, very important, quite important or not important for a primary medical degree qualifcation. The frst section consisted of twelve Level 1 outcomes which together were felt to encompass the competences required of medical graduates. The second section included, under each Level 1 outcome, a series of Level 2 outcomes. The third section consisted of the generic outcomes for Higher Education degrees previously agreed by the main Tuning Project. It was found that these generic outcomes encompassed many aspects of professionalism, as understood in medical schools. Respondents were also asked to rate the importance of 39 knowledge domains related to medical practice, and 14 practice settings in which students might gain experiential learning. Ranking of the outcomes and detailed statistical analysis of the responses was carried out looking for cluster efects such as 10 national infuences and diferences between categories of respondents. All data and analyses were evaluated and interpreted in Tuning taskforce workshops. The fnal outcomes framework, as part of a “Tuning Brochure” for medicine, was presented at a Sectoral Validation Conference, Brussels, June 007. An Expert Panel, external to the Tuning Task Force reviewed the outcomes framework and met with members of the Task Force. The Expert Panel endorsed the approach of the project and content of the outcomes framework. The fnal report and outcomes framework were presented to the European Commission in January 008. This process of discussion and agreement was at the heart of the Tuning (medicine) project. For example, “Ability to provide evidence to a court of law“ was rated very low by respondents as a core outcome and so was removed as a Level outcome. The original draft included the following Level outcomes: • Ability to design research experiments • Ability to carry out practical laboratory research procedures • Ability to analyse and disseminate experimental results These were rated very low by respondents in terms of importance for all graduates as core outcomes of the primary medical degree. The conclusion was that under the Level 1 outcome ‘Ability to apply scientifc principles, method and knowledge to medical practice and research’, no specifc Level outcomes should be included. Similarly, “Research skills”, with no further specifcation, is included as an outcome under Medical professionalism. This leaves it open to individual countries, schools or students to decide how to prioritise practical research experience, in keeping with their profle, educational philosophy or career intentions. Individual schools can also select additional learning outcomes in order to develop or preserve a distinct educational profle – for example, a specifc emphasis on research-related experience and skills - without compromising the essential competence of their graduates and their ftness to care for patients. The structure of the outcomes framework has been chosen to be useful to those involved in planning and designing new undergraduate medical degree programmes. The Level 1 outcomes describe domains of teaching, learning and assessment that lend themselves to becoming “curriculum themes”, with defned academic leadership and dedicated resources.

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