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MFAC 1525 Ageing and Endings A Student Guide Session 2: TP4 2011

September, 2011

Contents
WELCOME ...................................................................................................................................................4 Ageing and Endings Cycle A Changes from 2009............................................................................ 4 Staff involved in the course........................................................................................................... 5 GENERAL INFORMATION .............................................................................................................................6 Course themes .............................................................................................................................. 6 Aims of the course ........................................................................................................................ 6 Evaluation ..................................................................................................................................... 6 Scenario group session preparation .............................................................................................. 7 Timetable...................................................................................................................................... 7 Resources ..................................................................................................................................... 7 SCENARIO 1: ALMA JONES OSTEOPOROSIS ...............................................................................................8 Schedule ....................................................................................................................................... 8 Overview ...................................................................................................................................... 9 SGS 1: Introduction to the course and the scenario .................................................................... 10 SGS 2: Bone structure and development ..................................................................................... 13 SGS 3: Bone remodelling ............................................................................................................. 16 SGS 4: Interpreting trial reports .................................................................................................. 18 SGS 5: Fractures .......................................................................................................................... 30 SCENARIO 2: ANNIE SIMPSON ARTHRITIS ...............................................................................................33 Schedule ..................................................................................................................................... 33 Overview .................................................................................................................................... 34 SGS 6: Arthritis treatments ......................................................................................................... 35 SGS 7: Nerve lesions.................................................................................................................... 37 SCENARIO 3: ANDREW THEODOPOULOS BOWEL CANCER ......................................................................39 Schedule ..................................................................................................................................... 39 Overview .................................................................................................................................... 40 SGS 8: Biology of Neoplasia......................................................................................................... 41 SGS 9: Project presentations ....................................................................................................... 42 SGS 10: What causes Cancer?...................................................................................................... 51 SGS 11: Cultural attitudes to death and dying ............................................................................. 54 SGS 12: Cancer Death .................................................................................................................. 56 SGS 13: Pain management, expert tutorial reports, quiz and course wrap up ............................. 57

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ASSESSMENT ............................................................................................................................................ 59 Assessment overview .................................................................................................................. 59 Attendance ................................................................................................................................. 59 Academic honesty and plagiarism ............................................................................................... 60 Assignments and projects offered in AEA 2011 ........................................................................... 61 Due dates for registering your choice of assignments and projects ............................................. 62 Due dates for submission of project reports and assignments .................................................... 62 Assignments Assignment 1: New Biological Therapies for Inflammatory Arthritis ........................................... 63 Assignment 2: Skin Cancer: Educating the Public......................................................................... 65 Assignment 3: Communication Assignment Interview around a Theme from Ageing and Endings A .................................................................................................................................... 67 Assignment 4: Developing a Science-based Ageing and Endings A Wiki Entry ............................. 71 Assignment 5: To Screen or Not to Screen? Carcinoma of the Prostate ....................................... 74 Assignment 6: Euthanasia and Ethics .......................................................................................... 76 Projects Project 1: The Knee in Health and Disease .................................................................................. 78 Project 2: Polypharmacy and Falls in the Elderly ......................................................................... 80 Project 3: Primary Brain Tumours in Adults ................................................................................. 82 Project 4: Revising key concepts of Phase 1 Medicine ................................................................. 84 Project 5: Multiple Sclerosis ........................................................................................................ 86 Project 6: Interview with Health Professionals Working in Palliative Care .................................. 88 Project 7: Interview with Palliative Care Patients: Metastatic Malignancy Compared with End Stage Renal Failure ...................................................................................................................... 90

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Welcome
The Ageing and Endings courses in Phase one have been designed to help students gain an understanding of the health issues that arise particularly in older people, building upon learning done in previous courses. The A-cyle of the course in Term 4, 2011 focuses mainly on the course themes of: The Ageing process Degenerative disease Death, dying and palliative care In this course osteoporosis, arthritis and bowel cancer will be used to explore these themes.

Ageing and Endings Cycle A Changes from 2009


The previous offering of this course was in 2009. The Ageing and Endings A scenario group faciliators in 2009 indicated that the course was well received, challenging and encouraged student participation. The 2009 course was evaluated using the university CATEI evaluation and feedback system. The results from this evaluation demonstrated that 93% of CATEI respondents found the course challenging and interesting, and were also satisfied with the overall quality of the course. The major issue for students was the lack of feedback given during the course. This has been a problem for all Phase 1 courses and is partly due to the short duration of the courses. In 2011, we will endeavour to release the formative assessments as early as possible and also have included additional quizzes into the SG sessions to provide students with feedback of their learning. In 2009, as in the previous year, students found the focus on palliative care, death and bereavement emotionally confronting but many also found that these aspects of the course were very enlightening. Following from student feedback, we will endeavour to remind all lecturers to draw student attention to the key concepts of the lecture. Other changes to the course for 2011 include: All the SG sessions have been revised and a new SGS session (SGS 2) has been developed. More learning activities around the anatomy of the lower limb have been developed to include that of the ankle and foot. In response to student feedback, an additional lecture on cancer treatment has been included.

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Staff involved in the course


Course convenors
Dr Nalini Pather Department of Anatomy School of Medical Sciences Phone: 9385 8025 Email: n.pather@unsw.edu.au Prof. Ken Ashwell Department of Anatomy School of Medical Sciences Phone: 9385 2482 Email: k.ashwell@unsw.edu.au

Ageing and Endings Design and Implementation Group


Nalini Pather (Course convenor) Ken Ashwell (Course co-convenor) Gary Velan Nicole Jones Paul Bertrand Elizabeth Tancred Arun Krishnan Ramya Venkateswaran Frank Brennan Jan Maree Davis Kerrie Arnhold Anatomy Anatomy Pathology Pharmacology Physiology Anatomy Physiology (Neurologist) Cancer, Prince of Wales Palliative Care Palliative Care MESO

Welcome

With the assistance of Rachel Thompson, Patrick McNeil, Louise Lutze-Mann and Adi Torda, and with special thanks to the many individuals, including teachers, health professionals, patients and MESO staff, who have contributed so much to the course.

Other contacts
Ethics and legal aspects Dr Adi Torda Email: a.torda@unsw.edu.au Campus & Hospital Clinical skills Edna Koritschoner Phone: 9385 3427 Email: e.koritschoner@unsw.edu.au Quality of Medical Practice Dr. Rachel Thompson Email: rachelt@unsw.edu.au Phone: 9385 8038 Student Support Dr. Susan Allman Student Affairs Coordinator Email: s.allman@unsw.edu.au

Dr Silas Taylor Email: silas.taylor@unsw.edu.au

Medicine Education and Student Office


Elena Mankovskaia Adrian Buckland x51008 x58755 Timetable Manager Education Support Officer Ageing & Endings A Student Guide Session 2: TP4 2011 Page 5

General information
Course themes
The four themes for the Ageing and Endings domain are: Menopause The Ageing process Degenerative disease Death, dying and palliative care

The AE A course in 2011 emphasises the last three of these themes.

Aims of the course


The three scenarios focus on a range of issues surrounding osteoporosis, arthritis and cancer in ageing people. They aim to help students to: 1. 2. 3. 4. 5. 6. 7. describe the physiological and psychological changes associated with normal ageing in both males and females. describe the basic anatomical organisation of the upper and lower limbs. describe the characteristic features of synovial joints with particular emphasis on the shoulder, hip, knee and ankle joints, and understand the changes that occur with ageing. explain the molecular, cellular and clinical features of neoplasia, with particular emphasis on carcinoma of the colon. describe the structure and function of the cells of the peripheral nervous system (PNS), and explain the consequences of peripheral nerve injury. describe the anatomical and functional aspects of the perception of pain, and explain the mechanisms by which analgesics ameliorate pain. evaluate the social and ethical issues surrounding the end of life, including the issues faced by health professionals, patients, family and carers.

Evaluation
Periodically student evaluative feedback on both course and teaching is gathered. The UNSW's Course and Teaching Evaluation and Improvement (CATEI) Processes are used along with student focus groups, student forums, and at times additional evaluation and improvement instruments developed in consultation with the Faculty of Medicine's Program Evaluation and Improvement Group. Student feedback is taken seriously, and continual improvements are made to the course based in part on such feedback. Significant changes to the course will be communicated to subsequent cohorts of students taking the course through inclusion of information in student course guides, and in presentations by course convenors. Evaluation activities across the Faculty are strongly linked to improvements and ensuring support for learning and teaching activities for both students and staff.

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Scenario group session preparation


Please note the following scenario group sessions have essential preparation / readings to be completed before the session. These sessions will not make much sense to students and will not be able to fully participate unless students have prepared. Pre-reading is detailed in Blackboard. Week 1 Session SGS 1 SGS 2 SGS 3 SGS 4 SGS 5 SGS 6 SGS 7 5 SGS 8 SGS 9 SGS 10 6 SGS 11 SGS 12 7 SGS 13 Pain management presentation & Expert tutorial presentation Project presentations Gene vs environment presentation Cultural attitudes to death exercise prereading. Bring electronic devices for feedback Bone structure prereading, presentation, and create MCQs Bone remodelling prereading and presentation QMP online tutorial Prereading on fractures Presentation on alternative arthritis treatments Bring anatomy resources Activity

2 3 4

Further details on each activity, including detailed capability references, suggested readings and websites, and information on relevant disciplines, are contained in the eMed: Map at http://emed.med.unsw.edu.au .

Timetable
Consult the eMed Timetable for the details of session dates, times and locations.

Resources
Resources relevant to the course can be accessed on the eMed-Map and on the Ageing and Endings A Blackboard.

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Scenario 1: Alma Jones Osteoporosis


Schedule
Note: This schedule is subject to change. Refer to the eMed Timetable system and email updates sent to your UNSW email account for accurate times and locations. Learning Activity Scenario Plenary 1: Alma Jones: Osteoporosis Lecture 1: Histology, development and growth of bone Campus Clinical Skills Session 1: Pain and reflective writing Scenario Group Session 1: Introduction to the course and the scenario Lecture 2: Bones and joints of the upper limb Lecture 3: Biology of normal ageing Lecture 4: An introduction to fractures and types Lecture 5: Membrane transport and action potentials Lecture 6: Shoulder and arm anatomy Science Practical 1: Shoulder and arm anatomy Scenario Group Session 2: Bone Structure and Development Lecture 7: Calcium metabolism Lecture 8: Metabolic bone disease Lecture 9: QMP 1: Bias Lecture 10: Forearm and hand Science Practical 2: Bone: Normal and Abnormal Scenario Group Session 3: Bone remodelling Hospital Clinical Skills Session 1: Talking about pain & examination of the hand Lecture 11: Spinal cord and spinal nerves Lecture 12: Action potential generation and propagation Lecture 13: Neuromuscular Transmission Lecture 14: Brachial plexus and upper limb nerves Science Practical 3: Forearm and hand anatomy Scenario Group Session 4: Interpreting trial reports Lecture 15: QMP 2: Critical Appraisal Lecture 16: Vestibular system and balance Science Practical 4: Sensory Nerve Conduction and Carpal Tunnel Syndrome Lecture 17: Principle based ethics: Ethics in Practice Lecture 18: Falls in the elderly and proprioception Tutorial 1: Ethics 1 Tutorial 2: Action potentials Campus Clinical Skills Session 2: Loss of mobility, function and independence Lecture 19: Skeletal muscle physiology Lecture 20: Hip joint and associated structures Science Practical 5: Brachial plexus and nerve supply of the upper limb Scenario Group Session 5: Fractures Lecture 21: Pain neurotransmission Lecture 22: Coping with chronic pain Science Practical 6: Skeletal muscle physiology Tutorial Online: QMP Online Tutorial 5: Critical appraisal Tutorial Online: QMP Online Tutorial 6: Bias and Trial methodology Tutorial Online: Expert Online tutorial Principal Teacher Selecki, Yvonne De Permentier, Patrick Koritschoner, Edna Bertrand, Paul Pather, Nalini Lutze-Mann, Louise Tedla, Nicodemus Han, Eric Pather, Nalini Pather, Nalini Pather, Nalini Eisman AO, John Eisman AO, John Thompson, Rachel Pather, Nalini De Permentier, Patrick Velan, Gary Taylor, Silas Tancred, Elizabeth Han, Eric Vickery, Richard Pather, Nalini Pather, Nalini Jones, Nicole Thompson, Rachel Vickery, Richard Vickery, Richard Torda, Adrienne Delbaere, Kim Torda, Adrienne Vickery, Richard Koritschoner, Edna Head, Stewart Pather, Nalini Pather, Nalini Tancred, Elizabeth Bertrand, Paul Vollmer-Conna, Ute Head, Stewart Thompson, Rachel Thompson, Rachel Pather, Nalini

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Overview
Further details on each activity, including detailed capability references, suggested readings and websites, and information on relevant disciplines, are contained in the eMed Map at http://emed.med.unsw.edu.au . The focus is on Alma, who is in her late 60s, coming to an orthopaedic hand clinic. She lives alone and had a fall during which she stretched out her hand to protect her but sustained a Colles fracture. This was treated and has now healed, but she has continued to have tingling sensations in her hand with loss of sensation on the palmar surface of the thumb. There is also the issue of underlying osteoporosis and how to prevent further fractures. Students completing the work associated with this scenario should be able to: 1. Explain the psychological and biological aspects of normal ageing in both males and females. 2. Discuss the causes and consequences of falls in the elderly. 3. Explain the pathophysiology of osteoporosis and its complications. 4. Describe the structure and function of the bones, muscles, vessels and nerves of the upper limb, and the consequences of injury to branches of the brachial plexus. 5. Describe the ionic basis of the cell resting potential and the action potential. 6. Describe motor function, beginning with an action potential in a motor axon to neuromuscular transmission and then contraction of skeletal muscle. 7. Discuss individual approaches to promoting healthy ageing.

Scenario 1: Alma Jones Osteoporosis

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SGS 1: Introduction to the course and the scenario


Aims
This session aims to introduce the course and its assessments, and to help students to identify and explore the issues raised by the scenario. It will also explore issues of calcium intake and public health programs to increase calcium in the diet. Students will need a copy of the student guide.

Key concepts for the course


Ground rules, course assessment requirements. There are many risk factors for osteoporosis, not all are dietary. Dietary intake of calcium depends heavily on a few food groups. Dietary intake may be compromised by other factors that reduce calcium uptake. Low BMD often, but not exclusively, translates into morbidity after a fall. Building a high BMD as a young adult is protective against osteoporotic fracture in later life. Programs which promote calcium intake are driven by many factors.

Process
Activity 1. 2. 3. 4. 5. 6. 7. 8. Introductions and housekeeping Explore the scenario plenary and video and identify key issues Review the scheduled learning activities Osteoporosis risks Calcium intake Explore and evaluate a public health program Review the project and assignment options Preparation for SGS 2 Time 10 mins 15 mins 5 mins 20 mins 15 mins 30 mins 10 mins 2 mins

1. Introductions and housekeeping 10 mins

2. Explore the scenario plenary and video and identify key issues 15 mins

3. Review the scheduled learning activities 5 mins

4. Osteoporosis risks 20 mins Using the knowledge the students bring to the course together with what they have learned from the Plenary and associated lectures, the students will brain storm ideas about the risk-factors affecting bone mineral density (BMD), and will explore the relation of low BMD to morbidity. 5. Calcium intake 15 mins Students will evaluate the nutritional content in some sample foods and diets, with a particular focus on calcium. The distribution of calcium varies very markedly between foods, and certain diets pose a particular challenge to obtaining the required daily intake (RDI) of calcium.

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As a group, rank the 10 foods in the following list by estimating their calcium content. 1. a serve of spinach 6. apple 2. a boiled egg 7. a serve of tofu (hard) 3. a Weet-bix (by itself) 8. cappuccino 4. small tub of yogurt 9. small tin of sardines 5. pork chop 10. a cheese sandwich.

Food

Size of typical serve (g)

Approximate Calcium content per serve (mg)

6. Explore and evaluate a public health program 30 mins Public health programs that promote calcium intake are driven by many factors specific to the group or groups supporting the campaign. To start out, as a class explore the campaign found on the "Healthy Bones" website (http://www.healthybones.com.au/seniors.html) and have a discussion with reference to the issues below. 1. 2. 3. 4. Is the campaign driven by predominantly political, economic or medical objectives? (What are these objectives? Who is behind the campaign?). Do factors of ethnicity or nationality affect this campaign? What factors would you need to vary to make the campaign more suited to a different target audience? (e.g., children, teachers, parents, doctors). What is wrong with the following page on the website? http://healthybones.com.au/cowculator.html

Next, have a group discussion on public health messages in general, and those programmes seeking to reduce osteoporosis specifically, as they relate to the following issues: 1. What are the obstacles to compliance? 2. Who are the people who need to be targeted? 3. Could you sell the Asian community on increased dairy intake? 4. Who makes dietary decisions? 5. Who makes decisions about exercise? 6. What is the relationship between commercial interests and public health programmes? Finally, investigate the types of groups that might typically support a public health program. Three groups that might support an increase in calcium in the diet include: Health practitioners, the Government, Dairy companies. Discuss how these groups design a program, measure its success and avoid ethical issues. 7. Review the project and assignment options 10 mins All students must register for assignments and projects.

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Assignment and Project choices should be made at or before the next scenario group session and registered according to the instructions in the student guide. Registrations for projects or assignments with quotas must rd be made by 4pm Friday 23 September. Proposals for negotiated assignments must be made by 9am Monday th th 26 September. Registrations for non-quota assignments and projects must be made by 4pm on Friday 30 September.

References
Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes http://www.nhmrc.gov.au/publications/synopses/n35syn.htm Dietary guidelines for Australian Adults http://www.nhmrc.gov.au/publications/synopses/dietsyn.htm National Nutrition Survey: Nutrient Intakes and Physical Measurements http://www.abs.gov.au/AUSSTATS/abs@.nsf/0/95e87fe64b144fa3ca2568a9001393c0?OpenDocument Nutritional determinants of bone health: a survey of Australian Defence Force (ADF) Trainees http://www.dsto.defence.gov.au/publications/4072/DSTO-TR-1754.pdf NIH Office of Dietary Supplements. Dietary supplement fact sheet: Calcium http://ods.od.nih.gov/factsheets/calcium.asp "Healthy Bones" website (http://healthybones.com.au/)

8. Preparation for SGS 2 2 mins For SGS 2, each group must prepare a 10-minute presentation (preferably using PowerPoint) on the assigned topic relating to Bone from the list below. Each group must also prepare 5 MCQ style questions from their presentations and on their topic to be used in a Battle of the Wits style quiz of other groups. Some references are provided below. Students are encouraged to seek further information on these topics. References for each group are listed in Blackboard and in the Guide under SGS 2. Group 1 Bone structure Group 2 Bone development Group 3 Bone healing

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SGS 2: Bone structure and development


Aims
This session aims to help students to understand bone: its structure and development and healing. It will also provide an introduction to bone fractures and an understanding of the classification of fractures.

Key Concepts
Structure and development of bone Healing of bone Types and patterns of fracture

Process
Activity 1. 2. 3. 4. 5. Understanding the structure of bone and its development Understanding the classification of fractures Quiz Preparation for SGS 3 Round up session Time 45 mins 30 mins 30 mins 5 mins 10 mins

1. Understand the structure of bone and its development 45 mins Student groups are to present PowerPoint presentations on their topic addressing the relevant questions below. Each group will be given 10 minutes for presentation and 5 minutes for questions: Group 1: Bone structure Differentiate between cortical/compact bone and trabecular and spongy bone. Where are these types of bone found? Consider the structure of long bone. Describe the anatomy of long bone. How is the structure of bone adapted to withstand the forces that act on it? How does bone increase in length and diameter? What is rickets? Group 2: Bone development Which germ layer and embryological structures gives rise to bone? Differentiate between endochondral and intramembranous ossification. What are primary and secondary centres of ossification? Where are these for long bone? Compare the radiological features visible on X-rays of the normal upper limb of an adult and child. Group 3: Bone healing Describe the stages of bone healing after a fracture (inflammation, soft callus formation, hard callus formation and remodelling). What is healing by primary and secondary intention? Explain how bone formation and resorption varies with age? What possible factors can impede bone healing? References: 1. Standring S. (editor). (2008). Functional anatomy of the musculoskeletal system In Grays Anatomy: The th Anatomical Basis of Clinical Practice (40 ed., Chapter 5, pp 81-97), Churchill Livingstone. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search& vl(freeText0)=UNSW_DigiTool102417 2. BME/ME 456 Biomechanics, Bone Structure http://www.engin.umich.edu/class/bme456/bonestructure/bonestructure.htm

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3. 4. 5.

UNSW Embryology, Bone Development http://php.med.unsw.edu.au/embryology/index.php?title=Bone_Development Yang, Y.J., et al., Histology of Bone Medscape Reference http://emedicine.medscape.com/article/1254517-overview Kalfas, I.H. (2001). Principles of bone healing 1. Neurosurgical Focus, 10 (4) http://thejns.org/doi/pdf/10.3171/foc.2001.10.4.2

2. Understanding the classification of fractures 30 mins Using the information you found in preparation for this SGS, students should attempt to define each of the types of fracture listed below and give an example of each type. a. Based on aetiology Type Definition Example

b. Based on the fracture line Type Definition

Example

c. Based on involvement of overlying skin type Definition

Example

References: 1. Cannada, L.K. (2010) Fracture Classification. Orthopaedic Trauma Association www.ota.org/res_slide%20III/General/G06%20FX%20classification%20JTG%20rev%202-3-10.ppt 2. Adams, J.C. and Hamblen, D. (1999) Pathology of fractures and fracture healing in Outline of Fractures th including joint injuries. (11 ed., pp 3-18) Edinburgh, Churchill Livingstone. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr eeText0)=UNSW_DigiTool102412 3. Durschl, D.r. & Cannada, L.K. Classification of Fractures In Bucholz, R.W., et al. (2010) Rockwood and th Greens Fracture in adults. (7 ed. Vol 1. Chapter 2., pp 39-52). Philadelphia, Pa.: Lippincott Williams & Wilkins. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr eeText0)=UNSW_DigiTool120411

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3.

Quiz 30 mins a. Part of the homework for Activity 1, was for the groups to develop 5 MCQ questions on their topic for the quiz.

4. Preparation for SG 3 5 mins Bone Remodelling: Four groups will present information regarding each of the key concepts to the larger group, based on resources provided as pre-reading (10 minutes presentation plus 5 minutes for questions for each group) Group 1: Physiological remodelling of bone: Group 2: Definition and impact of osteoporosis: Group 3: Diagnosis and screening for osteoporosis: Group 4: Prevention and management of osteoporosis: References for each group are listed in BlackBoard and in the Guide under SGS 3. 5. Round up session 10 mins

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SGS 3: Bone remodelling


Aim:
The aim of this session is to explore the physiological turnover of bone, and how disturbances in this process can result in osteoporosis.

Key concepts:
Physiological remodelling of bone Diagnosis and screening for osteoporosis Prevention and management of osteoporosis

Process:
Activity 1. 2. 3. Group presentations on bone remodelling Osteoporosis quiz Preparation for SGS 4 Time 60 mins 45 mins 2 mins

1. Group presentations on bone remodelling 60 mins Four groups will present information regarding each of the key concepts to the larger group, based on resources provided as pre-reading (10 minutes presentation plus 5 minutes for questions for each group) Group 1: Physiological remodelling of bone: 1. Bone Physiology: http://courses.washington.edu/bonephys/physiology.html 2. ASBMR Bone Curriculum, Bone Growth and Remodeling: http://depts.washington.edu/bonebio/ASBMRed/growth.html 3. Invest in your bones,Beat the Break, Know and reduce your Osteoporosis Risck Factors, Osteoporosis Australia http://www.osteoporosis.org.au/images/stories/documents/research/BeatTheBreak_IOF_2007.pdf Questions to be addressed: What is the normal structure of bone? Which cell types are involved in bone growth and remodelling? What are the physiological mediators of remodelling in bone? What factors commonly impair bone remodelling, and might thereby increase the risk of osteoporosis? Group 2: Definition and impact of osteoporosis: 1. Bone Phsyiology: http://courses.washington.edu/bonephys/physiology.html 2. The Burden of Brittle Bones, Epidemiology, Costs & Burden of Osteoporosis in Australia 2007 http://www.osteoporosis.org.au/images/stories/documents/research/burdenbrittle_oa_2007.pdf 3. Invest in your bones,Beat the Break, Know and reduce your Osteoporosis Risk Factors, Osteoporosis Australia http://www.osteoporosis.org.au/images/stories/documents/research/BeatTheBreak_IOF_2007.pdf 4. Invest in your bones, Osteoporosis in Men, The silent epidemic strikes men too. Osteoporosis Australia http://www.osteoporosis.org.au/images/stories/documents/research/osteomen_IOF_2004.pdf Questions to be addressed: What is the definition of osteoporosis? How does it differ from osteomalacia? What is osteopenia? What is the impact of osteoporosis in Australian men and women? What is the prevalence of common osteoporosis-related fractures in Australia? What are the risk factors for fractures in people with osteoporosis?

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Group 3: Diagnosis and screening for osteoporosis: 1. ONeil, S., et al. (2004) Clinical Practice: Guidelines for the manatement of postmenopausal osteoporosis for GPs, Reprinted from the Australian Family Physistion Vol. 33. No.11, 2004. http://www.osteoporosis.org.au/images/stories/documents/research/postmenopausal_oneill_2004.pdf 2. Pocock, N., (2006) Measurement techniques in Osteoporosis, Duel energy x-ray absorptiometry, Quantitative Ultrasound. http://www.osteoporosis.org.au/images/stories/documents/research/measurementdxa_pocock_2006.pdf 3. Diagnosis of Osteoporosis with Bone Mineral Density Measurement Imaginis http://imaginis.com/osteoporosis/osteo_diagnose.asp 4. Diagnosis of Osteoporosis: http://courses.washington.edu/bonephys/opdiagnosis.html 5. Bone density: http://courses.washington.edu/bonephys/opbmd.html Questions to be addressed: What techniques are available for measuring bone density? What are T-scores and Z-scores? How should they be interpreted? What are the costs of osteoporosis to the Australian community? Apart from osteoporosis, what other disorders might cause pathological fractures? Group 4: Prevention and management of osteoporosis: 1. ONeil, S., et al. (2004) Clinical Practice: Guidelines for the manatement of postmenopausal osteoporosis for GPs, Reprinted from the Australian Family Physistion Vol. 33. No.11, 2004. http://www.osteoporosis.org.au/images/stories/documents/research/postmenopausal_oneill_2004.pdf 2. Pocock, N., (2006) Measurement techniques in Osteoporosis, Duel energy x-ray absorptiometry, Quantitative Ultrasound http://www.osteoporosis.org.au/images/stories/documents/research/measurementdxa_pocock_2006.pdf 3. Invest in your bones, Make it or Break it How exercise helps to build and maintain strong bones, prevent falls and fractures, and speed rehabilitation. http://www.osteoporosis.org.au/images/stories/documents/research/Invest_IOF_2006.pdf 4. Basic prevention: http://courses.washington.edu/bonephys/opprev.html 5. Treatment of Osteoporosis: http://courses.washington.edu/bonephys/optreatment.html#when 6. Vitamin D and adult bone health in Australia and New Zealand: Position Statement (2005 MJA 182(6) 281285 http://www.mja.com.au/public/issues/182_06_210305/dia10848_fm.html Questions to be addressed: What is the role of calcium intake in prevention of osteoporosis? What is the role of Vitamin D intake in prevention of osteoporosis? What is the role of exercise in prevention and management of osteoporosis? What treatments are available for established osteoporosis? What are the risks and benefits of the commonly used treatments for osteoporosis? 2. Osteoporosis quiz 45 mins Students will undertake the quiz based on the material covered in the presentations above. Questions will be presented in a Powerpoint file, with feedback provided at the conclusion of the quiz. 3. Preparation for SGS 4 2 mins Students are reminded that they are to complete the QMP Online tutorial #6 prior to SGS 4. http://web.med.unsw.edu.au/QMP/QMPTut6_2007/Tut6_Intro.htm

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SGS 4: Interpreting trial reports


Aims
To help students interpret the outcomes of clinical trials by experiencing the issues involved in designing studies. The session aims to develop knowledge about research trials and and study design skills. This scenario group session will teach students more about critical appraisal by getting them to think critically about what makes a trial and what makes it work well. This session will be backed up by an online tutorial, a lecture and a tutorial. Students are expected to have completed the QMP online tutorial no. 6 Bias, measurement and outcomes prior to this SGS.

Key concepts
The basics of good trial design and specifically the vital factors of: bias; confounding; compliance and data analysis (including loss to follow-up and intention to treat).

Process
Activity 1. 2. 3. Design Task Reflection and discussion Preparation for SGS 5 Time 100 mins 10 mins 5 mins

1. Design task 100 mins In this session the students are given the task of designing a trial to determine the efficacy of a new preventative/protective intervention for falls targeted at people with osteoporosis. The session will be driven by a worksheet and PowerPoint file which will break-up and structure the tasks the students have to perform. Split the students into 3 groups each addressing a different intervention: a. Exercise routine focusing on balance. b. Environmental modifications for community-dwelling subjects. c. Wearing a hip protector (reduces injuries, but not incidence of falls).

Figure 1. A. The hip protectors have an outer shield made of hard plastic and are placed in the pockets of a specially designed undergarment, B. Schematic drawing of the hip protector. From Parkkari et al., (1998) Age and Ageing 27: 225-229

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Process: The students have a worksheet in their course guide that is broken into boxes with data that they need to supply. The session is structured to run in 3 blocks and in each one the students will address specific questions about the design of their clinical trial, as directed by their worksheet. The small groups are competing to see who can design the most rigorous and cost-effective trial, as judged from their cumulative score. 2. Reflection and Discussion 10 mins To summarise the session, run a reflection discussion with the whole group on the following: Which study of the three that you have designed do you believe would provide the most useful data for improving quality of life for people at risk of osteoporotic fractures? What aspects of the trial design process went well and why? What aspects of the trial design process could have been done better?

References
Greenhalgh. T. (1997). How to read a paper: Assessing the methodological quality of published papers. BMJ, 315, 305-308. Accessed 18.08.11 at: http://bmj.bmjjournals.com/cgi/content/full/315/7103/305 Okasha, M. (2001). Epidemiological research. Student BMJ, 9, 261-304. Accessed 18.08.11 at: http://er.library.unsw.edu.au/er/cgi-bin/eraccess.cgi?url=http://student.bmj.com/student/viewarticle.html?id=sbmj0108277 Centre for Evidence Based Medicine. (2004). Glossary of EBM terms. University of Toronto Libararies and University Health Network. Webpage Accessed 18.08.11 at: http://www.cebm.utoronto.ca/glossary/

3. Preparation for SGS 5- 5 mins


SGS 5 will focus on types of fractures and some clinical cases. To prepare for this session students are to look up information on the basic types of fractures and how they usually occur. Students can ether use the references listed for SGS 5 on classification of fractures, or alternately do their own search for this information.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 19

Student Worksheet
Setting the scene You are 3 small groups of Geriatricians based at 3 different hospitals. The many elderly people you care for are at risk of falling and hurting themselves and these falls often have the serious outcome of a fracture of the hip and pelvis. You have seen how appalling these fractures can be for the quality of life and life expectancy of these patients (see Box 1). To help you focus on the key factors, you decide to proceed with a typical patient in mind: Mrs Myrna Travis. Age 81, lives alone in her own free-standing house. She fell and suffered a wrist fracture 3 years ago. After that incident she had a bone mineral density scan, and was found to have a T-score at the hip of -2.6. Mrs Travis weighs 55 kg and has a low BMI. She has mild asthma and takes an inhaled glucocorticoid as a preventer. She is otherwise healthy and is on no other regular medication. Turning to the literature, you find that there is a lack of good trials on the three main possible interventions. You are ready to commence another clinical trial, and you are good at getting research grants and like a challenge. The next step is to meet together to begin to design the trial. The scenario group should divide into 3 groups A, B and C with 3-5 people in each. Groups A, B and C will each investigate an intervention for the elderly to prevent falls or reduce the risk of fractured hips resulting from a fall. Follow this worksheet, and work in your small group on your trial design. You will return to the larger group at the end of each of the 3 blocks to discuss and get your answers scored based on a PowerPoint presentation of suggested answers. Facilitators will give points based on the PowerPoint presentation and at their or the groups discretion. Keep a tally of the scores and decide on an overall winner at the end of the session. The trial groups are allowed to take it in turns to access: QMP online tutorials (specifically the AE A tutorial QMP MS6 on Bias) Links to EBM Toolkits in the References (listed in the Introduction) of the Online Tutorial Box 1: Falls & hip fractures in the elderly in Victoria, Australia From 1998 to 1999 11,845 older persons were admitted to hospital in Victoria for falls, 3,465 for fractured hips. Older persons falls account for 124,611 bed days in a single year. Fractured hips required 49,060 of these, and cost the government 36 million dollars annually. Unfortunately, many of these individuals will never return home, and a substantial number of them will die needlessly as a result of their hip fractures. Falls account for 76.8% of injury-related hospital admissions in older people (>65yrs). Most fall injuries at home (46%)... The average length of stay in hospital...with fractured hip is 16.4 dayscosting $10,392 per admission. From: Best Buys in Fall Injury Prevention, Summary 2001 Hazard, vol: 48,1. Victorian Injury Scheme and Applied Research (VISAR); VicHealth http://www.monash.edu.au/muarc/VISU/hazard/haz48.pdf and Cassell, E. (2001). Prevention of hospital treated fall injuries in older people. Hazard, Sept Vol. 48, 7-12. http://www.studentbmj.com/issues/01/08/education/277.php

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 20

BLOCK 1
1 Basic Intervention A. Exercise for Balance B. Environmental Modifications Here, the intervention is assessment and modification of the elderly persons home environment, specifically to reduce the risk of falls within the home. A community occupational therapist team will visit the patients home and grade it in terms of its likelihood to cause or prevent falls. They will assess it fully for specific modifications (pre-agreed and standardised) that are deemed to improve the home for someone at risk of falling: e.g. handrails, decluttering of hallways and rooms, fixing floor-coverings and laying down non-slip bathroom flooring. C. Hip Protector For this group, the intervention is an exercise regimen that helps build up strength and balance. The intervention group will be asked to attend an exercise class once a week that aims to tone and strengthen their postural muscles and improve their balance. The primary aim of this intervention is to reduce the risk of falls, rather than to affect bone mineral density. In this trial, the intervention you are investigating involves fitting and providing a hip protector and advising on its use. The hip protector is of standard size and has to be worn all the time and be worn correctly to be of maximum effectiveness. See Fig. 1 for a drawing of the hip protector.

Clinical Question

In BLOCK 2 you will be able choose between 3 detailed interventions according to their cost and the budget that you wish to expend. Clinical Question Clinical Question Clinical Question Q1. What Clinical Question are the geriatricians interested in answering? (4 points in total) Q1. What Clinical Question are the geriatricians interested in answering? (4 points in total) Q1. What Clinical Question are the geriatricians interested in answering? (4 points in total)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 21

BLOCK 1
1 Baseline Assessment A. Exercise for Balance B. Environmental Modifications C. Hip Protector Baseline Assessment Baseline characteristics are measured for all subjects and shown at the beginning of the Results section. The authors should clearly outline the population in their trial and show any factors that might modify the benefit of the intervention or predict adverse reactions. The baseline measurements are important for two main reasons: 1. Clinicians reading the paper need to be able to see if the participants in the trial match the patients in their own practice. This way they can determine the extent to which the results of the trial may be applied to their clinical practice. This is external validity. 2. Confounders are factors that if not evenly distributed between the trial groups may mask an intervention effect or cause an apparent beneficial effect where none exists. Potential confounding factors are always present but randomisation of the trial groups hopefully distributes these factors evenly between the groups. Further reading: Burgess, D, Gebski, V and Keech, A. (2003). EBM: Trials on trial. Baseline data in clinical trials. MJA, 179 (2), 105-107. Q2. What factors might affect the outcome of your trial? Some of these will be GENERAL and some SPECIFIC to your trial. List suggestions under these two headings and note how you will assess them. (0.5 points per correct answer, max. 4) Q2. ANSWERS: Q2. ANSWERS: Q2. ANSWERS: GENERAL GENERAL GENERAL

Baseline Assessment

SPECIFIC

SPECIFIC

SPECIFIC

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 22

1 Choice of criteria

A Exercise for Balance

B Environmental modifications

C Hip Protector

Selection criteria Should be broad enough that the study results will be applicable to a large segment of the population so that external validity is high. Inclusion criteria define your theoretical and trial population subjects. Your inclusion criteria for this trial might be: 1. Australian citizen or permanent resident dwelling in the region of study. 2. Age > 80 years. 3. At least one other risk factor for falling (see list your specific factors in Q2 might be appropriate). However, you need to exclude people with conditions that would bias the result or invalidate the trial (e.g. if bedbound!). These are exclusion criteria. Q3. What are the major exclusion criteria? (1 point for each, max. 4) Q3. ANSWERS Q3. ANSWERS

Choice of criteria

Q3. ANSWERS

Sample Size General

Sample size This depends on the size of the response that you are likely to see with the intervention and the size of the difference between the intervention and control groups that you think will be statistically and clinically significant. The statistical significance: When analysing results from a study with a large sample size, a statistical test is more likely to show a level of statistical significance even if the intervention effect is small. A trial with a small sample size will prove harder to show a statistical significance, even if there is a real and substantial intervention effect. Clinical Significance requires you to decide how large a reduction in the rate of falls is likely to make it worthwhile for this intervention to be used. The answer to this question may depend on who you make the decision for: as a GP for an individual patient whose financial and other circumstances will vary; as a recommendation to Government to fund a program for the elderly population in general who live at home etc. By requiring subjects for inclusion in the study to have at least one risk factor for falls, you are able to reduce the sample size while maintaining a reasonably high rate of falls in the control group and so achieving the same statistical significance as required for a larger group of subjects where that didnt require a risk factor for falls.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 23

BLOCK 2
2 Study Structure A. Exercise for Balance B. Environmental Modifications C. Hip Protector A randomised controlled trial (RCT) is the ideal study design for investigating this type of question. RCTs can be run as a parallel or a crossover study.
Trial Period
RANDOMIZE
Period 1 Wash-out Period 2 Treatment B

Treatment A

RANDOMIZE

Treatment A

Treatment B

Treatment B

Treatment A

Parallel trial

Cross-over Trial

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 24

Study Structure

Q4. What type of study structure for the RCT will best suit your intervention? (2 points) What intervention (or none) would be appropriate for the control group? (2 points) Following this you would recruit, enrol and randomise your subjects into the trial. Randomisation is essential to the design of a Randomised Controlled Trial (RCT). The bias of a trial is reduced considerably by allocating subjects to the various intervention groups by a specified random method. It should be done after enrolment so that both participant and trial manager cannot influence which group the participant is allocated to. Q4. ANSWER (4 points) Q4. ANSWER (4 points) Q4. ANSWER (4 points)

2 Blinding

A. Exercise for Balance Q5. How would you blind the study? Q5. ANSWER (4 points)

B. Environmental modifications Q5. How would you blind the study? Q5. ANSWER (4 points)

C. Hip Protector Q5. How would you blind the study? Q5. ANSWER (4 points)

Q6. Write a brief ethical justification for the use of a control group, especially if they are blinded. (4 points)

Q6. Write a brief ethical justification for the use of a control group, especially if they are blinded. (4 points)

Q6. Write a brief ethical justification for the use of a control group, especially if they are blinded. (4 points)

Ethics

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 25

2 Quality control

A Exercise for Balance Quality control The level of attendance at weekly classes; a 6 monthly visit by an exercise therapist or community nurse; are methods that could be used to assess that the exercise regime is being carried out properly and in the most effective manner.

B Environmental modifications Quality control Probably best done by having a risk assessment made before and after the modifications. Ideally this would be done by two separate teams, randomised to each visit one half of the houses before modifications, and the other half after.

C Hip Protector Quality control Quality control is not likely to be a major issue provided all patients are issued the same model, have an appropriate size of hip protector and are given the same advice on how and when to wear it. A 6-month follow-up to monitor whether it is being worn/fitted correctly would be useful. Compliance Compliance is a significant issue. However, patients in the intervention group can be asked by their doctor whether they were wearing the hip protector at the time of the fall and this should be recorded. This can be used during data analysis (see later).

Compliance Compliance is a major issue because it is a long-term study and the exercise regimen demands the ongoing commitment of the subjects. The most generally useful principle is intention to treat which would include data from all subjects in the treatment group in the analysis irrespective of their adherence to the exercise regimen. This controls for the fact that any subsequent real-world compliance with the regimen will face similar hurdles. Another approach is to closely monitor compliance and only analyse data for the treatment group from those who meet certain pre-determined criteria. This tests the efficacy of the intervention, but in an artificial manner.

Compliance Compliance would not seem to be a major issue. However de-cluttering the house and remove trip objects from the floor are things that may not be complied with. A random visit at some time during the study to note the actual state of the dwelling and perform a risk assessment might yield data to correlate with frequency of falls.

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Compliance

BLOCK 3
3 A. Exercise for Balance B. Environmental modifications C. Hip Protector

Choose intervention: Q6 choices

Q7. Choose which of the following 3 interventions seems the best choice, using the information that you have available (e.g. sample size, length of study and your common sense). We estimate that you would require 250 subjects in each group (intervention and control) to reduce the chance of a Type II error to below 20%. Assume the 10-year absolute hip fracture risk for 80 year old women is 10%. (Points 4/2/1) 1. $1250 per subject per 1. $4000 per subject over 2 years. 1. $800 per subject over 2 years. year. Drive subject to Extensive home modifications Supply and fit hip protector, and exercise class once per (rails, ramps, replace provide fitting inspection and week ($10 for class, $15 shower/baths with no-trip, replacement undergarments for bus). no-slip systems etc) and every 6 months. Controls get a monthly home visits for similar garment with pads in maintenance and tidying. non-protective locations. 2. $500 per subject per year. Offer free weekly exercise class to subject ($10 for class). 2. $3000 per subject over 2 years. Extensive home modifications (rails, ramps, replace shower/baths with no-trip, no-slip systems etc). 2. $600 per treatment-group subject over 2 years. Supply and fit hip protector with protective pads only on one hip. Supply new garment with protected side swapped, midway through study, and replacement undergarments every 6 months. 3. $500 per treatment-group subject over 2 years. Supply and fit hip protector, and provide replacement undergarments every 6 months.

3. $350 per subject per year. Two free exercise classes, a take home video, and 6monthly home visits by exercise therapist ($20 for classes, $30 for video, $300 for 2 visits). RECORD YOUR CHOICE and reason:

3. $500. Basic modifications and advice (remove rugs, grip tape on stairs etc).

RECORD YOUR CHOICE and reason:

RECORD YOUR CHOICE and reason:

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 27

3 Confounders and bias

A. Exercise for Balance Confounders and bias Q8. List possible important confounders and considerations for data analysis specific to the intervention you have chosen (1 point each, max. 4) Q8. ANSWERS

B. Environmental modifications Confounders and bias Q8. List possible important confounders and considerations for data analysis specific to the intervention you have chosen (1 point each, max. 4) Q8. ANSWERS

C. Hip Protector Confounders and bias Q8. List possible important confounders and considerations for data analysis specific to the intervention you have chosen (1 point each, max. 4) Q8. ANSWERS

Handling dropout

Handling dropout A difficult issue as the benefit may increase over time. Dropout is likely to be higher from the intervention group due to the demanding nature of the intervention which may introduce bias. Again, the solution depends on the clinical question investigated. If you see the drop-out as reflecting the real-world situation and so want to include them in your analysis, you would need to start with a larger intervention group to achieve statistical significance. If you do not have enough information to decide how much larger the intervention group should be, you could recruit new subjects to replace intervention group subjects as they drop out.

Handling dropout Subjects may drop out of the study as they become too frail to live at home. Providing access to homecare facilities for both groups of subjects may reduce dropout, and be more effective in terms of both cost and study power than recruiting a larger initial number of subjects.

Handling dropout Drop out would not be expected to be different between treatment and control groups and can be handled by increasing the initial enrolment.

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Outcomes to measure Final thoughts

Outcomes to measure The outcomes that should be measured here are pretty specific and relatively easy to measure: Q9. Can you list them? (1 point for each outcome,max. 4) Q9. ANSWERS: 1.

2.

3.

4.

Quality of life measures are more important in some of these trials than others. For instance, with the hip protector group, wearing the protector may be so uncomfortable that the patients quality of life goes down considerably. On the other hand, they might feel liberated from worry about falling and become more mobile and enjoy life more. Will the study you have come up with answer your Q1. (the Clinical Question asked)?

***Total up the points for each Trial Design Group. Who won!?***

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SGS 5: Fractures
Aims
This session aims to help students to understand the different types of fractures, why they occur, principles of treatment & common complications resulting from different types of fractures.

Key Concepts
General principles of management of fracture Immediate and delayed complications of fracture

Process
Activity 1. 2. 3. Treatment modalities for fracture Four cases of fracture Preparation for SGS 6 Time 40 mins 60 mins 2 mins

1. Treatment modalities for fracture 40 mins. Using the reference provided, prepare to report back to the group on the type of treatment, the circumstances in which it is used and the potential complications arising from treatment Group 1: Traction Group 2: Closed reduction Group 3: Open reduction Group 4: Fixations internal & external References: 1. Adams, J.C. and Hamblen, D. (1999) Principles of fracture Treatment in Outline of Fractures including joint th injuries. (11 ed., Chapter 3. pp 28-51.) Edinburgh, Churchill Livingstone. 2. Boudrieau, R.J., and Sinibaldi, K.R. (1992) Principles of long bone fracture management. Semin Vet Med Surg. 7(1):44-62. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr eeText0)=UNSW_DigiTool97937 2. Four cases of fracture 60 mins Suggested time: 15 minutes for preparation, 5 -10 minutes for reporting back to the large group Task: For groups 1-2 and group 4: Study the history and radiographs provided, with the help of the recommended references, prepare to report on the following issues: 1. Which bone is fractured? 2. How old do you think the patient is? 3. Are the fragments displaced, and if so why are they so displaced? 4. How do you think the fracture happened? 5. What methods of treatment would be appropriate? 6. What complications might you expect to occur? Group 1 Reference: th Adams, J.C. and Hamblen, D. (1999) Elbow and Forearm In Outline of Fractures including joint injuries. (11 ed., Chapter 11. pp 164-176.) Edinburgh, Churchill Livingstone.

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Group 2 Reference: Adams, J.C. and Hamblen, D. (1999) Special Features of Fractures in Children in Outline of Fractures including th joint injuries. (11 ed., Chapter 5. pp 74-78 and 159-163) Edinburgh, Churchill Livingstone. Group 4 Reference: th Adams, J.C. and Hamblen, D. (1999) Leg and Ankle in Outline of Fractures including joint injuries. (11 ed., Chapter 15. pp 252-260) Edinburgh, Churchill Livingstone. For group 3: Study the history and radiographs provided, with the help of the recommended references, prepare to report on the following issues: 1. Which bone(s) are involved? 2. Describe the pathological changes in the affected bones 3. How old do you think the patient is? 4. How susceptible are the affected bones to fracture? Why? What type of fracture is this condition likely to cause? 5. What methods of treatment would be appropriate? 6. What complications might you expect to occur? Group 3 Reference: th Adams, J.C. and Hamblen, D. (1999) Spine and Thorax in Outline of Fractures including joint injuries. (11 ed., Chapter 8. pp 99-106) Edinburgh, Churchill Livingstone. Students Note: Students should be aware that the classification systems used in this SGS are not the only available and which system is best is a point of contention amongst orthopaedic specialists. You are strongly recommended to read, in your own time, the following references that address these issues. When reading these papers keep the following questions in mind: What is the purpose of classification of fractures? Are the current classification methods appropriate? Sufficient? Are there any other types of classifications? References 1. Muller, M.E., Nazarian, S., Koch, P. & Schatzker, J. (1990) The comprehensive classification of fractures of long bones. Berlin, Springer-Verlag. 2. Bernstein, M.S., Monaghan, B.A., Silber, J.S. & Delong, W.G. (1997) Taxonomy and treatment-a classification of fracture classifications. J Bone Joint Surg., 79: 706-709. 3. Preparation for SGS 6 Presentations of alternative arthritis treatments Students are to pre-read and and prepare a short (3-5 slide) PowerPoint presentation to summarise evidence associated with their groups as detailed below. Students are encouraged to seek further information on these topics. Group 1: Hyaluronan (also hyaluronic acid) Bellamy, N., Campbell, J., Welch, V., Gee, T.L., Bourne, R. and Wells, G.A. (2006). Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005321. DOI: 10.1002/14651858.CD005321.pub2. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005321/pdf_fs.html Group 2: Transcutaneous electrical nerve stimulation (TENS) Rutjes, A.W.S., et al. (2009). Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD002823. DOI: 10.1002/14651858.CD002823.pub2. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002823/pdf_fs.html

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 31

Group 3: Glucosamine (+/- chondroitin) Towheed, T., et al. (2005). Glucosamine therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002946. DOI: 10.1002/14651858.CD002946.pub2 http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002946/pdf_fs.html Group 4: Copper bracelets Richmond. S.J. et al. (2009). Therapeutic effects of magnetic and copper bracelets in osteoarthritis: A randomised placebo-controlled crossover trial. Complementary Therapies in Medicine Vol17.5:249-256 http://sirius.library.unsw.edu.au:9003/sfx_local?issn=0965-2299&date=2009&volume=17&issue=5&spage=249

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 32

Scenario 2: Annie Simpson Arthritis


Schedule
Note: This schedule is subject to change. Refer to the eMed Timetable system and email updates sent to your UNSW email account for accurate times and locations.

Learning Activity Scenario Plenary 2: Arthritis: Annie Simpson Lecture 23: Arthritis 1: Rheumatoid Arthritis Science Practical 7: QMP Practical Scenario Group Session 6: Arthritis treatments Hospital Clinical Skills Session 2: Assessing function in an interview & examining the knee Lecture 24: Knee joint and associated structures Lecture 25: Anatomy of the Ankle and Foot Lecture 26: Arthritis 2: Degenerative Arthritis and Gout Lecture 27: Anatomy of Nerve root Lesions of the lower limb Science Practical 8: Hip and thigh anatomy Scenario Group Session 7: Nerve lesions Lecture 28: Management of chronic musculoskeletal pain Lecture 29: Other treatments for arthritis/pain Science Practical 9: Pain and the action of NSAIDS

Principal Teacher McNeil, Patrick McNeil, Patrick Thompson, Rachel Bertrand, Paul Taylor, Silas Pather, Nalini Tancred, Elizabeth McNeil, Patrick Pather, Nalini Pather, Nalini Tancred, Elizabeth Faux, Steven Faux, Steven Binder, Trudie

Scenario 2: Annie Simpson Arthritis

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 33

Overview
Further details on each activity, including detailed capability references, suggested readings and websites, and information on relevant disciplines, are contained in the eMed Map at http://emed.med.unsw.edu.au . The focus is on a rheumatology meeting considering two cases, one of osteoarthritis and one of rheumatoid arthritis. A number of health care practitioners are present at the meeting: rheumatologists, physiotherapists, occupational therapitss, and junior doctors. The cases are discussed and recommendations and referrals made. In addition, two patients are present at the plenary that discuss their experience with having rheumatoid arthritis and osteoarthritis. To support student learning in relation to arthritis and related issues in the elderly. Students completing the work associated with this scenario should be able to: 1. 2. 3. 4. Describe the structure and function of the bones, muscles, vessels and nerves of the lower limb. Describe the structure and function of synovial joints, using the hip, knee and ankle joints as examples. Compare and contrast the causes, consequences and likely outcomes of degenerative joint disease (osteoarthritis) and rheumatoid arthritis. Describe the pathways of pain transmission from the peripheral to the central nervous system, and the mechanisms by which analgesics and adjunctive treatments ameliorate pain.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 34

SGS 6: Arthritis treatments


Aims
To review the physiology covered in this scenario To review the scenario plenary and the learning issues To evaluate alternative arthritis treatments Scientific method Evidence-based medicine Practical approaches to disability

Key concepts

Process
Activity 1. 2. 3. 4. 5. Physiology quiz Explore the scenario plenary and identify key issues List learning goals and preview learning activities related to this scenario Discussion and presentation of "alternative" arthritis treatments Resources for SGS 7 Time 30 mins 15 mins 10 mins 50 mins 2 mins

1. Physiology Quiz 30 mins 2. Explore the scenario plenary and identify key issues 15 mins 3. List learning goals and preview learning activities related to this scenario 10 mins From the previous discussion, the group should list what they consider the interesting and/or key issues of this scenario. Students should then work through the scheduled learning activities in relation to these issues. 4. Discussion and presentation of alternative arthritis treatments 50 mins A. Class discussion of alternative treatments (15 minutes): As a class, discuss how alternative medicine fits in with mainstream medicine. What are the benefits and drawbacks of having alternative options available? What are the broader issues relating to a role of alternative (integrative) therapies in treating patients? 1. Why do patients seek alternative treatments? 2. Why particularly for arthritis? 3. If an alternative therapy does no harm, should it be permitted? 4. Would you encourage you patient to seek a 'harmless' alternative therapy? 5. Should 'harm' be defined to include wasted patient time, energy and money? 6. What are the roles of the pharmacist in supporting the sales of these alternative therapies? 7. If you were to conduct research, what barriers do you foresee in terms of finding funding? 8. If your research were conducted, how would you disseminate that knowledge to patients and GPs? 9. Do alternative therapies have a potentially beneficial placebo effect? 10. Is the placebo effect worth more than debunking them? 11. Does the doctor's have a role to help with an integrated therapy package? 12. What happens to patient trust if the doctor refuses? B. Group presentations (25 minutes): Each group must present a 5 minute Powerpoint presentation using 3-5 slides, as outlined in SGS 5. The goal is to summarise the evidence associated with the assigned alternative therapy and come to a clear conclusion as to the associated benefits and risks.

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Group 1: Hyaluronan (also hyaluronic acid) Bellamy, N., Campbell, J., Welch, V., Gee, T.L., Bourne, R. and Wells, G.A. (2006). Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005321. DOI: 10.1002/14651858.CD005321.pub2. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005321/pdf_fs.html or http://www.ncbi.nlm.nih.gov/pubmed/16625635 Group 2: Transcutaneous electrical nerve stimulation (TENS) Rutjes, A.W.S., et al. (2009). Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD002823. DOI: 10.1002/14651858.CD002823.pub2. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002823/pdf_fs.html http://www.ncbi.nlm.nih.gov/pubmed/19821296 Group 3: Glucosamine (+/- chondroitin) Towheed, T., et al. (2005). Glucosamine therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews 2005, Vol 18; Issue 2. Art. No.: CD002946. DOI: 10.1002/14651858.CD002946.pub2 http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002946/pdf_fs.html http://www.ncbi.nlm.nih.gov/pubmed/15846645 Group 4: Copper bracelets Richmond. S.J. et al. (2009). Therapeutic effects of magnetic and copper bracelets in osteoarthritis: A randomised placebo-controlled crossover trial. Complementary Therapies in Medicine Oct-Dec Vol17.5:249256 http://sirius.library.unsw.edu.au:9003/sfx_local?issn=0965-2299&date=2009&volume=17&issue=5&spage=249 http://www.ncbi.nlm.nih.gov/pubmed/19942103 C. Evaluation (10 minutes): Each group in turn should now critique the quality of the studies that they summarised. In the course of evaluating the therapy, students should identify claims made about the mechanism of action and assess whether these claims are reasonable in the light of their knowledge of physiology, pharmacology, and of the disease process of arthritis. Discuss each of the following issues: Which joints has the therapy been effective/approved for? Is the therapy effective as an injectable, ingestible or topical? What are the proper measures to determine if the therapy has reduced arthritis? What is the best study design for the therapy? 5. Resources for SGS 7 2 mins Students must bring their anatomy lecture and practical notes and/or anatomy text to the next session, which will involve some neurological cases related to the upper limb.

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SGS 7: Nerve lesions


Aims
Understand the consequences of damage to the nerves of the upper limb. Compare and contrast the joint abnormalities caused by rheumatoid arthritis and osteoarthritis, as well as their clinical manifestations. Segmental innervation of the upper limb. Likely sites and consequences of nerve lesions in the upper limb. Nerve regeneration. Differences between osteoarthritis and rheumatoid arthritis.

Key concepts

Process
Activity 1. 2. Peripheral nerve lesions affecting the upper limb Rheumatoid arthritis and osteoarthritis comparison activity Time 70 mins 40 mins

1. Peripheral nerve lesions affecting the upper limb 70 mins Each group will then present their answers/explanations to the whole class. PowerPoint slides containing feedback on the cases will be provided, but students should be encouraged to try to answer the questions before this is shown. You should allow approximately 15 minutes per case (or else you will run out of time!). 2. Comparison of rheumatoid arthritis and osteoarthritis 40 mins Students to work in small groups (2-3 students per group) to complete the following table, writing their answers on butchers paper.

Osteoarthritis Definition

Rheumatoid arthritis

Epidemiology (incidence, age groups, gender)

Risk factors

Joints typically affected

Pathological changes in affected joints

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Characteristics of joint pain (exacerbating and relieving factors) Typical features on examination of affected joints

Characteristic X-ray appearances of affected joints

Local (peri-articular) and systemic complications

Principles of management

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 38

Scenario 3: Andrew Theodopoulos Bowel Cancer


Schedule

Scenario 3: Andrew Theodopolous Bowel Cancer

Note: This schedule is subject to change. Refer to the eMed Timetable system and email updates sent to your UNSW email account for accurate times and locations. Learning Activity Scenario Plenary 3: Andrew Theodopolous: bowel cancer Lecture 30: Cellular Biology of Neoplasia Scenario Group Session 8: Biology of neoplasia Lecture 31: Eicosanoids and NSAIDs Lecture 32: Tissue biology of neoplasia Campus Clinical Skills Session 3: The MSAL & putting it all together Lecture 33: Colorectal anatomy and histology Lecture 34: Colorectal neoplasms Tutorial 3: Neoplasia Science Practical 10: Knee Joint and Associated anatomy Scenario Group Session 9: Project presentations Lecture 35: Molecular biology of cell growth and neoplasia 1 Lecture 36: Molecular biology of cell growth and neoplasia 2 Science Practical 11: Cancer and genetic markers Lecture 37: Central nervous system pharmacology / opioids Lecture 38: Iron uptake, metabolism and stores Tutorial 4: Ethics Tutorial 2 Science Practical 12: Pathology of Neoplasia Scenario Group Session 10: What causes cancer? Hospital Clinical Skills Session 3: Musculoskeletal Screening Examination Lecture 39: Clinical approach to anaemia Lecture 40: Ethics and palliative care Science Practical 13: Patterns of anaemia Lecture 41: Clinical management of cancer Lecture 42: Antineoplastics Science Practical 14: Anatomy of the Foot and Ankle Scenario Group Session 11: Cultural attitudes to death and dying Lecture 43: Bowel Cancer: Principles of a surgical approach Lecture 44: Post-operative infections Science Practical 15: Iron, iron storage & iron metabolism Lecture 45: Environmental carcinogenesis Lecture 46: Practical cancer pain management Tutorial 5: Expert tutorial Science Practical 16: Histology and Neoplasms of the Colon Scenario Group Session 12: Cancer death Lecture 47: Psychosomatic models of illness Lecture 48: Palliative care Lecture 49: Grief and bereavement Lecture 50: Drugs and the elderly Scenario Group Session 13: Pain management, expert tutorial reports, quiz and course wrap up Lecture 51: AntiCancer Drugs Principal Teacher Segelov, Eva Kan, Betty Velan, Gary Day, Ric Kan, Betty Koritschoner, Edna Ashwell, Ken Kan, Betty Velan, Gary Pather, Nalini Ashwell, Ken Lutze-Mann, Louise Lutze-Mann, Louise Lutze-Mann, Louise Binder, Trudie Jones, Graham Torda, Adrienne Velan, Gary Venkateswaran, Ramya Taylor, Silas Lindeman, Robert Brennan, Frank Velan, Gary Segelov, Eva Segelov, Eva Tancred, Elizabeth Ashwell, Ken Gett, Rohan Mitchell, Hazel Galea, Anne Hawkins, Nick Brennan, Frank Pather, Nalini Velan, Gary Velan, Gary Vollmer-Conna, Ute Barbato, Michael Connell, Simone Morris, Margaret J Jones, Nicole Griffith, Renate

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 39

Overview
Initial scenario: Andrew Theodopoulos is a 75 year old, non-English speaking (NES), Greek widower who lives with his son and family. He has become increasingly fatigued. The son was concerned but his father kept denying symptoms, until one day he became quite unwell. At the GPs office: he admitted to some rectal bleeding and pain, as well as increasing constipation. On examination, the abdomen was normal but on rectal exam, a large mass was palpable and there was blood on the glove. The GP sends him to a surgeon who performed proctoscopy and biopsied an obvious mass. Pathology showed moderately differentiated adenocarcinoma and staging CT scan showed small liver metastases. His CEA was elevated but LFTs were normal. Results were given to the son, who had been translating for the father. The son asks that the diagnosis not be given to the father. After a lot of explanation, the family agree that the team can discuss the condition with Andrew, because treatment is needed to prevent complete obstruction. The prognosis is discussed with the patient and family using an interpreter. The patient is referred to an oncologist and expresses a desire for aggressive treatment so he can return to visit family in Greece. Chemoradiation is commenced, with the aim of down staging the tumour to relieve the obstruction. The palliative care team is introduced, to help with symptoms and also organise community follow-up. Development scenario: Andrew copes well with the treatment and in feels better. The primary cancer improves significantly as do the metastatic lesions. He has a low anterior resection with a temporary colostomy, followed by further chemotherapy. He stops this whilst he returns to Greece for 4 months to visit family. He is well for most of this until the last few weeks when he starts to lose weight and become fatigued. On return to Sydney, he sees the oncologist who finds that the liver disease is now worse. Further chemotherapy is discussed but he decides against active treatment. He renews his contact with the Palliative Care team who visit him at home and provide services. He deteriorates rapidly and is admitted to the hospice when his son cannot cope with caring for him at home. He dies one week later. To support student learning in relation to pain, bowel cancer, death, dying and palliative care. Students completing the work associated with this scenario should be able to: 1. 2. 3. 4. 5. Describe the gross and microscopic anatomy of the colon. Explain the molecular pathogenesis and biological effects of neoplasms with particular emphasis on carcinoma of the colon. Describe the principles underlying the use of surgery and antineoplastic drugs (chemotherapy) in the management of malignant neoplasms. Discuss the role of palliative care and opioid analgesics in the management of advanced cancer. Evaluate the social and ethical issues surrounding death from cancer, including the issues faced by health professionals, patients, family and carers.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 40

SGS 8: Biology of Neoplasia


Aims
Explore the scenario and the related learning issues. Discuss the biology of neoplasia and its clinical manifestations, as well as the impact of a diagnosis of cancer. Definition and nomenclature of neoplasia. Differences between benign and malignant neoplasms.

Key concepts

Process
Activity 1. 2. 3. 4. 5. 6. Explore the scenario plenary and identify key issues List learning goals Preview learning activities The biology of neoplasia The impact of neoplasia Project presentations preparation for SGS 9 Time 10 mins 10 mins 5 mins 45 mins 30 mins 5 mins

1. Explore the scenario plenary and video and identify key issues 10 mins 2. List learning goals 10 mins 3. Preview learning activities related to this scenario 5 mins 4. The biology of neoplasia 45 mins 5. The impact of neoplasia 30 mins Students should reflect on their personal experiences and attitudes towards cancer, in order to answer the following questions: How might personal and family experiences, as well as cultural and societal attitudes, shape individuals responses to a diagnosis of malignancy? What fears or expectations might a person experience when they are informed of a diagnosis of malignancy? How would these issues influence your approach if required to inform a patient about a diagnosis of malignancy? 6. Projects presentations preparation for SGS 9 5 mins In the next SG session, students have time set aside for presentations of project for peer feedback before they are submitted for assessment. It is expected that all project groups will report.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 41

SGS 9: Project presentations


Aims
To report on findings by groups investigating material for the projects.

Key concepts
Living with chronic disease Aged care assistance and facilities

Process
Activity 1. 2. 3. Establish an order and a time limit for presentations Project presentations and discussion Preparation for SGS 10 Time 5 mins 110 mins 5 mins

1. Establish an order and a time limit for presentations 5 mins Establish an order and a time limit for the presentations at the beginning of the session. Timing should allow for the presentation, questions/discussion and feedback as indicated below. 2. Presentations and discussion ~110 mins Generic criteria for giving feedback on oral presentations (see handout)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 42

Feedback form: Assessment of the group project presentation


Project title: Scenario Group: Project Group members: Date: Time:

Criteria EXPLANATION OF PROJECT Project aim, methods and findings were clearly explained; Findings are based on the evidence available; Methodology is appropriate and adequate for the task. PRESENTATION Oral presentation was clear, well structured and easily understood; Presentation demonstrated consistency in style e.g. PowerPoint slides Timing was controlled so that most aspects were covered; Audio visual aids or handouts were clear, well structured and easy to read. UNDERSTANDING Project team appeared to have a good understanding of the topic; Project has an introduction and conclusion Able to answer audience questions. STIMULATING LEARNING Presentation was interesting; Significant issues and unanswered questions were highlighted; I learned a lot from this presentation; This presentation stimulated me to find out more about the topic. TEAMWORK The transition from one speaker to the other went smoothly Team members demonstrated support for the speaker i.e. not talking amongst themselves when a group member was presenting Presenters have minimal overlap in their presentations The group engaged the audience and demonstrated team unity

Grade (P-, P, P+)

Comments

Did the group meet the assessment criteria for the group project adequately (i.e. a Pass level)? Yes / No Please add specific comments (more space overleaf):

P- represents a relatively poor and/or incomplete performance, in terms of the assessment criteria P represents a performance that achieves most of the stated criteria, in a reasonably effective manner P+ means that all the criteria were attained, and that they were done in a way that demonstrated a clear understanding of and mastery of the topic. Full definitions at: http://medprogram.med.unsw.edu.au/med3802web.nsf/page/Grading+System

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Ageing & Endings A Student Guide Session 2: TP4 2011 Page 44

Feedback form: Assessment of the group project presentation


Project title: Scenario Group: Project Group members: Date: Time:

Criteria EXPLANATION OF PROJECT Project aim, methods and findings were clearly explained; Findings are based on the evidence available; Methodology is appropriate and adequate for the task. PRESENTATION Oral presentation was clear, well structured and easily understood; Presentation demonstrated consistency in style e.g. PowerPoint slides Timing was controlled so that most aspects were covered; Audio visual aids or handouts were clear, well structured and easy to read. UNDERSTANDING Project team appeared to have a good understanding of the topic; Project has an introduction and conclusion Able to answer audience questions. STIMULATING LEARNING Presentation was interesting; Significant issues and unanswered questions were highlighted; I learned a lot from this presentation; This presentation stimulated me to find out more about the topic. TEAMWORK The transition from one speaker to the other went smoothly Team members demonstrated support for the speaker i.e. not talking amongst themselves when a group member was presenting Presenters have minimal overlap in their presentations The group engaged the audience and demonstrated team unity

Grade (P-, P, P+)

Comments

Did the group meet the assessment criteria for the group project adequately (i.e. a Pass level)? Yes / No Please add specific comments (more space overleaf):

P- represents a relatively poor and/or incomplete performance, in terms of the assessment criteria P represents a performance that achieves most of the stated criteria, in a reasonably effective manner P+ means that all the criteria were attained, and that they were done in a way that demonstrated a clear understanding of and mastery of the topic. Full definitions at: http://medprogram.med.unsw.edu.au/med3802web.nsf/page/Grading+System

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 45

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 46

Feedback form: Assessment of the group project presentation


Project title: Scenario Group: Project Group members: Date: Time:

Criteria EXPLANATION OF PROJECT Project aim, methods and findings were clearly explained; Findings are based on the evidence available; Methodology is appropriate and adequate for the task. PRESENTATION Oral presentation was clear, well structured and easily understood; Presentation demonstrated consistency in style e.g. PowerPoint slides Timing was controlled so that most aspects were covered; Audio visual aids or handouts were clear, well structured and easy to read. UNDERSTANDING Project team appeared to have a good understanding of the topic; Project has an introduction and conclusion Able to answer audience questions. STIMULATING LEARNING Presentation was interesting; Significant issues and unanswered questions were highlighted; I learned a lot from this presentation; This presentation stimulated me to find out more about the topic. TEAMWORK The transition from one speaker to the other went smoothly Team members demonstrated support for the speaker i.e. not talking amongst themselves when a group member was presenting Presenters have minimal overlap in their presentations The group engaged the audience and demonstrated team unity

Grade (P-, P, P+)

Comments

Did the group meet the assessment criteria for the group project adequately (i.e. a Pass level)? Yes / No Please add specific comments (more space overleaf):

P- represents a relatively poor and/or incomplete performance, in terms of the assessment criteria P represents a performance that achieves most of the stated criteria, in a reasonably effective manner P+ means that all the criteria were attained, and that they were done in a way that demonstrated a clear understanding of and mastery of the topic. Full definitions at: http://medprogram.med.unsw.edu.au/med3802web.nsf/page/Grading+System

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 47

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 48

Feedback form: Assessment of the group project presentation


Project title: Scenario Group: Project Group members: Date: Time:

Criteria EXPLANATION OF PROJECT Project aim, methods and findings were clearly explained; Findings are based on the evidence available; Methodology is appropriate and adequate for the task. PRESENTATION Oral presentation was clear, well structured and easily understood; Presentation demonstrated consistency in style e.g. PowerPoint slides Timing was controlled so that most aspects were covered; Audio visual aids or handouts were clear, well structured and easy to read. UNDERSTANDING Project team appeared to have a good understanding of the topic; Project has an introduction and conclusion Able to answer audience questions. STIMULATING LEARNING Presentation was interesting; Significant issues and unanswered questions were highlighted; I learned a lot from this presentation; This presentation stimulated me to find out more about the topic. TEAMWORK The transition from one speaker to the other went smoothly Team members demonstrated support for the speaker i.e. not talking amongst themselves when a group member was presenting Presenters have minimal overlap in their presentations The group engaged the audience and demonstrated team unity

Grade (P-, P, P+)

Comments

Did the group meet the assessment criteria for the group project adequately (i.e. a Pass level)? Yes / No Please add specific comments (more space overleaf):

P- represents a relatively poor and/or incomplete performance, in terms of the assessment criteria P represents a performance that achieves most of the stated criteria, in a reasonably effective manner P+ means that all the criteria were attained, and that they were done in a way that demonstrated a clear understanding of and mastery of the topic. Full definitions at: http://medprogram.med.unsw.edu.au/med3802web.nsf/page/Grading+System

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 49

3. Preparation for SGS 10 5 mins Student pairs are to research their chosen gene/factor and to report for ten minutes on it in the next scenario group session. References for each factor are listed in BlackBoard and in the Guide under SGS 10. Genetic factors 1. p53 2. MLH1 3. FAP Environmental factors 4. Western diet 5. Sedentary lifestyle 6. Stress 7. Inflammatory bowel disease

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 50

SGS 10: What causes Cancer?


Aims
To explore the contribution that genes and environmental factors play in the induction of colon cancer, to review teh screening procedures for colorectal cancer and to explore future research directions.

Key concepts
Carcinogenesis Molecular epidemiology Screening

Process
Activity 1. 2. 3. 4. Genes vs. Environment in bowel cancer presentations Screening for colon cancer Where to from here in prevention and research? Preparation for SGS 11 Time 50 mins 20 mins 30 mins 2 mins

1. Genes vs. Environment in bowel cancer presentations 50 mins After each presentation, the group votes as to whether the gene/agent is definitely, probably, maybe or unlikely to cause colon cancer, and in which proportion of the population (few, moderate, many) to fill in the grid on the next page. Genetic factors 1. p53 2. MLH1 3. FAP Environmental factors 4. Western diet 5. Sedentary lifestyle 6. Stress 7. Inflammatory bowel disease

References: This is by no means an exhaustive list and students are encouraged to perform their own Medline search for other references. The references below are mostly available in full text through the Biomed Library. General references: Chemical Carcinogenesis Research Information System. CCRI is a database sponsored by the National Cancer Institute containing data and information on carcinogens, mutagens and tumor promotors. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?CCRIS QuickTime movie from University of Maryland School of Medicine on carcinogenesis, including What environmental factors are associated with the development of cancer? http://aquaticpath.umd.edu/appliedtox/module7.html Genetic Calvert, P.M. & Frucht, H. (2002). The genetics of colorectal cancer. Annals of Internal Medicine. 137(7), 60312. http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0003-4819&date=2002&volume=137&issue=7&spage=603 p53 Braithwaite, A.W., Royds, J.A. & Jackson, P. (2005). The p53 story: layers of complexity. Carcinogenesis. 26(7), 1161-9. http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0143-3334&date=2005&volume=26&issue=7&spage=1161

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MLH1 Rowley, P.T. (2005). Inherited susceptibility to colorectal cancer. Annual Review of Medicine. 56, 539-54. http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0066-4219&date=2005&volume=56&issue=&spage=539 FAP Bronner, M.P. (2003). Gastrointestinal inherited polyposis syndromes. Modern Pathology. 16(4), 359-65. http://www.nature.com/modpathol/journal/v16/n4/pdf/3880773a.pdf Environmental Factors Diet and exercise Williams, M.T. & Hord, N.G. (2005). The role of dietary factors in cancer prevention: beyond fruits and vegetables. Nutrition in Clinical Practice. 20(4), 451-9. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr eeText0)=UNSW_DigiTool97938 Roberts, C.K. & Barnard, R.J. (2005). Effects of exercise and diet on chronic disease. Journal of Applied Physiology. 98(1), 3-30. http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=8750-7587&date=2005&volume=98&issue=1&spage=3 Stress Gotay, C.C. (2005). Behavior and cancer prevention. Journal of Clinical Oncology. 23(2):301-10. http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0732-183X&date=2005&volume=23&issue=2&spage=301 IBD Bernstein, C.N., Blanchard, J.F., Kliewer, E. & Wajda, A. (2001). Cancer risk in patients with inflammatory bowel disease: a population-based study. Cancer. 91(4), 854-62. http://www3.interscience.wiley.com/cgi-bin/fulltext/77004830/PDFSTART Prevention Asano, T.K. & McLeod, R.S. (2004). Non steroidal anti-inflammatory drugs (NSAID) and Aspirin for preventing colorectal adenomas and carcinomas. Cochrane Database of Systematic Reviews. (2):CD004079, 2004. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004079/pdf_fs.html 2. Screening for colon cancer 20 mins The following is a list of tests that can be used to screen for colon cancer. Which have been/are being used as screening tests for the population? At what age would individuals normally be screened? Which tests are used as diagnostic tools rather than screening? What is the basis of each of the following tests? i.e what are they examining? Note that two of the tests (which?) are still in clinical trials as screening tools. Test FOBT Colonoscopy Sigmoidoscopy Barium Enema CT Colonography Stool DNA Mutation Tests CT = computed tomography; FOBT = fecal occult blood test. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 52 Used for screening Used for diagnosis Basis of test

3. Where to from here in prevention? 30 mins Based on their research about risk/predisposition to cancer, each student pair gives recommendations for prevention in patients in each category in table 1 above. 4. Preparation for SGS 11 2 mins Students are to read the articles for the Cultural attitudes to death group exercise, available under SGS 11 and Blackboard. Students to bring their electronic devices to complete the course evaluation at the next SGS

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SGS 11: Cultural attitudes to death and dying


Aims
To prepare questions for the Expert Tutorials. To reach an understanding of intercultural differences in attitudes to death and dying. To deal sensitively and appropriately with end-of-life issues with patients and families from culturally and linguistically diverse backgrounds. To be aware of common issues which face all cultural groups in the area of death and dying. To provide an opportunity for feedback to the course designers and to the facilitator. To understand cultural diversity. To understand cultural dimensions to disclosure and truth telling around the area of death and dying. To understand the cultural differences in relation to bereavement.

Key concepts

Process
Activity 1. 2. 3. 4. 5. 6. 7. Completing course and facilitator evaluations Developing questions for the Expert Tutorials Development of scenario Cultural attitudes to death video Cultural attitudes to death group exercise Report back to group for activity 4 Preparation for SGS 13 Time 15 mins 15 mins 15 mins 30 mins 15 mins 25 mins 5 mins

1. Completing course and facilitator evaluations 15 mins 2. Developing questions for the Expert Tutorials 15 mins 3. Development of scenario 15 mins 4. Cultural attitudes to death and dying 30 mins 5. Cultural attitudes to death group exercise 15 mins Group 1 Attitudes to disclosure of serious illness to the patient Is death talked about or a taboo subject? Reflect on your own cultural perspectives in relation to these issues. Group 2 Do Australian doctors and hospital staff understand different cultural perspectives? As death approaches, what are the most important things for families? Reflect on your own cultural perspectives with reference to these issues? Group 3 What are the cultural differences apparent in the grieving and bereavement process? Are there differences between Australian born and overseas born members of the same cultural groups? What role does religion or spiritual beliefs play in the setting of grief or bereavement? Reflect on your own cultural perspectives with reference to these issues.

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References: Firth, S. (2005). End-of-life: a Hindu view. The Lancet. 366(9486), 682-686
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9486&spage=682

Sachedina, A. (2005). End-of-life: the Islamic view. The Lancet. 366(9487), 774-779.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9487&spage=774

Dorff, E.N. (2005). End-of-life: Jewish perspectives. The Lancet. 366(9488), 862-865.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9488&spage=862

Keown, D. (2005). End-of-life: the Buddist view. The Lancet. 366(9489), 952-955.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9489&spage=952

Engelhardt Jr, H.T. & Smith Iltis, A. (2005). End-of-life: the traditional Christian view. The Lancet. 366(9490), 1045-1049.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9490&spage=1045

Markwell, H. (2005). End-of-life: a Catholic view. The Lancet. 366(9491), 1132-1135


http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9491&spage=1132

Baggini, J. & Pym, M. (2005). End-of-life: the Humanist view. The Lancet. 366(9492), 1235-1237.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9492&spage=1235

6. Report back 25 mins 7. Preparation for SGS 13 5 mins Pain Management presentations Further information and references for each group are listed in Blackboard and in the Guide under SGS 13. Group 1: Side effects of opioids including sedation Group 2: Addiction, tolerance and dependence Group 3: Morphine as the 'last resort'

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SGS 12: Cancer Death


Aims
To understand death as a natural part of life. To understand the role of and the importance of carers in the dying process and the impact that this has on them. To understand the role of the palliative care services both in the hospital and community settings. Death is inevitable and care of the dying requires the same degree of professional expertise as any other area of medicine. Care of dying patients by relatives, families and friends has both positive and negative aspects. Role of palliative care services in meeting the needs and preferences of dying patients and their carers with the prevention and relief of suffering.

Key concepts

Process
Activity 1. 2. 3. 4. Interviews with professionals in palliative care End of Life Care: Herbie Carer issues Reminder Preparation for SGS 13 Time 30 mins 50 mins 25 mins 5 mins

1. Interviews with professionals in palliative care 30 mins 2. End of Life Care: Herbie 50 mins 3. Carer issues 25 mins 4. Reminder Preparation for SGS 13 5 mins Pain Management presentations Students must work in three groups to read the recommended reading for their allocated area. Each group is to give a 5-10 minute presentation to the class covering the topics below. Further information and references for each group are listed in Blackboard and in the Guide under SGS 13. Group 1: Side effects of opioids including sedation Group 2: Addiction, tolerance and dependence Group 3: Morphine as the last resort

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SGS 13: Pain management, expert tutorial reports, quiz and course wrap up
Aims
This session is in two main parts. The first part of the session will look at pain management, building on the lecture on this topic. It aims to support understanding of: Cancer pain and its treatment The use of opioids and the opioid myths Barriers to good pain management: Addiction issues Tolerance/dependence issues The myth of inevitable sedation The myth that opioids should be kept until the last What to use when the pain gets really bad Fear of hastening death The importance of good pain management advice to patient and carers In the second part students will present their reports on expert tutorials, answer quiz questions and wrap up the course. The aim is to encourage students: To resolve unanswered questions raised by the scenario and the course. To support preparation for the course examination.

Key concepts
Options for the treatment of cancer pain Barriers to good pain relief in cancer patients Major myths surrounding opioid use in the cancer patient Addressing any unresolved learning issues from scenario and course

Process
Activity 1. 2. 3. 4. Cancer pain management Pain management group exercise Report back on expert tutorials Quiz and course wrap up Time 30 mins 30 mins 30 mins 25 mins

1. Cancer pain management 30 mins 2. Pain management group exercise 30 mins At the end of SGS 11 students were divided into three groups and required to read the recommended reading for their allocated area. Each group is to give a 5-10 minute presentation to the class covering the topics below. Group 1: Side effects of opioids including sedation Q1 What are the expected side effects? Q2 How would you manage those? Q3 What strategies could be used to improve compliance? Q4 How would you tell whether someone is taking their pain medications correctly?

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Group 1 Reference: Woodruff, R. (2004) Barriers to good pain control. In Palliative Medicine: Evidence-based symptomatic and th supportive care for patients with advanced cancer. (4 ed., pp 82-84.) South Melbourne, Vic. : Oxford University Press. (available in Blackboard) Group 2: Addiction, tolerance and dependence Q1 Is addiction likely in patients with cancer pain? Q2 How would you discuss issues of addiction, tolerance and dependence with a cancer patient who is experiencing pain? Q3 What other concerns or points would you need to make in such a situation? Group 2 Reference: Woodruff, R. (2004) Opioid Analgesics. In Palliative Medicine: Evidence-based symptomatic and supportive th care for patients with advanced cancer. (4 ed., Chapter 9. pp 96-110.) South Melbourne, Vic. : Oxford University Press. (available in Blackboard) Group 3: Morphine as the last resort Q1 When should morphine be introduced in the cancer patient? Q2 What would you anticipate would be the main concerns and fears patients and their families would have about their use of morphine? Q3 How would you explain such a situation to a relative who was worried about morphine hastening the death? Group 3 References: World Health Organization (1990) Analgesic Ladder. http://www.who.int/cancer/palliative/painladder/en/ Woodruff, R. (2004) Patient Opiophobia. In Palliative Medicine: Evidence-based symptomatic and th supportive care for patients with advanced cancer. (4 ed., pp 107-108.) South Melbourne, Vic. : Oxford University Press. (available in Blackboard) Dahl, J. and Portenoy, R. (2004) Myths about controlling pain. Journal of Pain and Palliative Care Pharmacotherapy. 18(3), 55-58. http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr eeText0)=UNSW_DigiTool97933

3. Report back from expert tutorials 30 mins 4. Quiz and course wrap up 25 mins In AE B in 2012 the focus will be on Menopause and Breast Cancer.

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Assessment
Assessment overview
Assessment in this course involves an assignment, a group project, a course examination and attendance requirements. You must complete one group project from the set list, and one assignment. The assignment may be chosen from the set list or negotiated on a topic of your choice which is relevant to the themes of the course. You are reminded of the program requirements to negotiate at least one assignment, and to complete at least one communication assignment, during Phase One. Successful completion of the assignment and project work is necessary before your exam results will be released. You are reminded that questions relating to the practicals, tutorials and scenario group sessions may be included in the end of course examination. Refer to the Phase 1 guide and Medicine Program website for information on the format of the end of course examination and for detailed progression rules.

Assessment

A formative online assessment will also be available. While your final result for the course will largely be determined by your performance in the end of course examination, the assignment and project work is also an important component of the assessment for the course. The graded assignments and projects will form part of the portfolio examination at the end of your second year, where they will be used as evidence of your achievement in each of the capabilities.

Attendance
You are expected to attend all classes and it is to your advantage to do so. The Faculty has set minimum attendance requirements for this course. You must: attend all scenario group sessions. Students with approved abscences need to attend at least 80% of scenario group sessions AND attend all hospital and campus clinical skills sessions and ethics tutorials sessions. Students with approved abscences need to attend at least 80% of hospital and campus clinical skills sessions and ethics tutorials. Facilitators / Tutors will keep attendance records in scenario group sessions, hospital clinical skill sessions, campus clinical skills sessions, and ethics tutorials. If you fail to comply with the above attendance requirements, the Faculty has the right to refuse to allow you to sit the end-of-course examination. As a result, an Unsatisfactory Fail (UF) will be recorded as your result for the course. All applications for exemption from attendance at forthcoming classes of any kind must be made as outlined in the Faculty policy on extra-curricular activities affecting attendance in MBBS Program. (http://www.med.unsw.edu.au/medweb.nsf/resources/csp1/$file/Extra-curriculActivitiesPolicy.pdf). In the case of illness or of absence for some other unavoidable cause, you may be excused by the Registrar for non-attendance at classes for a period of not more than one month or, on the recommendation of the Dean, for a longer period. Where required, explanations of absences from classes should be delivered to the Medical Education and Student Office and include medical certificates, where applicable. Medical certificates should NOT be given to teaching staff. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 59

It is your responsibility to frequently check your official student email account and the Timetable for assigned classes and any changes. Ignorance of classes, which are scheduled in the Timetable, is not an acceptable excuse for non-attendance. You can only attend classes to which you are allocated. You may not attend practicals or other classes at different times to your timetable. Tutors may ask you to leave if you are not in your allocated class. You are expected to be punctual in attendance at all classes.

Academic honesty and plagiarism


Students should be familiar with the UNSW Student Conduct Policy and the policies relating to code of conduct particularly relating to academic misconduct and plagiarism https://my.unsw.edu.au/student/academiclife/assessment/StudentConductPolicy.html The Faculty of Medicine regards the maintenance of academic integrity by staff and students as a matter of the highest priority. The Faculty participates in the Universitys use of the similarity detection software Turnitin (see http://www.turnitin.com/static/home.html ). Students work submitted to the eMed Portfolio system will be compared to other items in the eMed system, to material on the Internet, electronic publications and to items in the Turnitin database. You can check your own assignments and projects against Turnitin before you submit it to eMed Portfolio by using the link in the Blackboard module for this course located under Assessment Activities. The Learning Centre website is main repository for resources for staff and students on plagiarism and academic honesty. These resources are located at: http://www.lc.unsw.edu.au/plagiarism/index.html

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 60

Assignments and projects offered in AEA 2011


Assignments Title A1 A2 A3 A4 A5 A6 New biological therapies for inflammatory arthritis Quota - 50 Skin cancer: Educating the public Quota - 25 Communication Assignment Interview around a theme from AEA Quota - 80 Developing an AEA Wiki Entry Quota - 20 To screen or not to screen? Carcinoma of the prostate Euthanasia & Ethics Focus capability Social and cultural aspects of health and disease Patient assessment & management Using basic and clinical sciences Effective communication Effective communication Development as a Reflective practitioner Using basic and clinical sciences Development as a reflective practitioner Social and cultural aspects of health and disease Self directed learning and critical evaluation Understanding ethics and legal responsibility Social and cultural aspects of health and disease

There is no exempt assignment being offered in this course Projects Title P1 P2 P3 P4 P5 P6 P7 The Knee in Health and Disease Polypharmacology and falls in the Elderly Primary brain tumours in adults Revising key concepts in Phase I Medicine Multiple sclerosis Interview with health professionals working in palliative care Quota 10 groups Interview wth palliative care patients: metastatic malignancy compared with end stage renal failure- Quota 5 groups Focus capability Using basic and clinical sciences Patient assessment & management Using basic and clinical sciences Social and cultural aspects of health and disease Patient assessment and management Self directed learning and critical evaluation Self directed learning and critical evaluation Teamwork Patient assessment & management Self directed learning and critical evaluation Teamwork Development as a reflective practitioner Teamwork Development as a reflective practitioner

Please note that project groups will be expected to report to their scenario group in scenario group session 9, and that all members of the group will be expected to answer questions from the group and the facilitator on the presentation. Please use the Discussion area in Blackboard for posting questions regarding assignments and projects. Enquiries that relate specifically to the tasks of the particular assignment or project and related content, should be directed to the appropriate thread in the Discussion areas located under Assessment Activities on Blackboard.

Word Count
The word count for assignments and projects includes all the text in the report, apart from the cover page and the reference list. Assignments are up to 2000 words and projects up to 2500 words, unless there is an explicit exception for any individual assignment or project. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 61

You should format your report in accordance with the specification on the Medicine program website, and include a word count. Ensure that you carefully reference your written work using the UNSW Medicine APA referencing style (http://web.med.unsw.edu.au/infoskills/apa/apa.html). Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Due dates for registering your choice of assignments and projects


Registration for assignments and projects with quotas Submission of proposals for negotiated assignments Registration for all other assignments and projects 4pm Friday 23 September 9am Monday 26 September 4pm Friday 30 September
th th rd

*NB: Only one student from your group project group should register in eMed on behalf of the group. Once you have been named in a project group you will not be able to register for any other group projects.

Due dates for submission of project reports and assignments


Submission of Assignments Submission of Negotiated and Communication Assignments Submission of Project Reports and any supporting evidence You may submit earlier if this suits your study schedule. 9am Monday 17 October 9am Monday 24 October 9am Monday 31 October
st th th

Negotiated assignments
Proposals for a negotiated assignment must be submitted by 9 am Monday 26 September, 2011 (Monday of week 2) to the eMed Registrations system. Do not proceed with your proposed assignment until you get approval from the Convenor. Please note that first year students should not negotiate an assignment until at least the last course of their first year. See the program website for information on the process for negotiating an assignment: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Negotiated%20-%20P1?open&login

Submission to eMed Portfolio


Information on submitting assessments to eMed is available at: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Portfolio?OpenDocument&Login Students submitting a website should submit a zip file to eMed; but if the website is too large (over 10Mb) then you should submit a dummy file on eMed and hand in a CD that is clearly labelled with your student number and the receipt number of your project to the Medical Education and Student Office. The dummy file should be a single page word document specifying your name, student number and project title and state that a CD has been submitted to the Medical Education and Student Office. Please note that if you submit the website on CD, it will be destroyed after marking and will not be available for your Portfolio. Please refer to the Medicine 3802 Program website for penalties that you will incur if you submit after the due dates. ( http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Penalties%20-%20P1?open&login) If there are extenuating circumstances that prevent you from meeting the due date for submission, contact the course convenor before the due date to request an extension. In most cases a medical certificate or a similar level of documentation will be required.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 62

Assignment 1: New Biological Therapies for Inflammatory Arthritis


Note this assignment has a quota of 50 students. Please register your interest in this assignment by 9.00 am on the Monday of week 2.

Graduate capabilities assessed in this assignment:


Social and Cultural Aspects of Health and disease Patient Assessment and Management

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Aims:
To understand the indications, potential benefits and potential toxicity of modern biological treatments for Rheumatoid Arthritis (RA) and Spondyloarthritis (SpA) including agents that inhibit tumour necrosis factor (TNF) and interleukin-6 (IL-6), and agents that target B-lymphocytes or T-lymphocyte interactions. To understand how new expensive treatments can be accessed by Australian patients in an affordable fashion via the Pharmaceutical Benefits Scheme (PBS). To experience the impact of chronic illness and its treatment.

Course themes and related learning activities:


This project relates to the course themes: The Ageing Process, and Degenerative Diseases.

Task description and time allocation guide:


Modern treatments for RA and SpA that target specific inflammatory cytokines or immune cells have revolutionised the treatment for these chronic inflammatory diseases. Some patients call them miracle drugs because of the dramatic improvement they have experienced. These treatments are expensive, costing tens of thousands of dollars per year. For this assignment, review the pathological mechanisms that occur in RA and SpA as presented in lectures, and research how the new biological treatments are targeted to interrupt this pathology. The names of these drugs include infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), abatacept (Orencia), tozilizumab (Actemra), and rituximab (Mabthera). How effective are these drugs in treating these diseases? Are there any potential side-effects or precautions doctors should consider when prescribing them? Are they suitable for all patients with RA and SpA? How much do these drugs cost and who pays for them? How can patients access these drugs and who can prescribe them? What are their downsides are they really miracle drugs? Interview a patient in person or by phone (contact details will be provided see below) who is taking one of these drugs for RA or SpA (including Psoriatic arthritis, Ankylosing spondylitis). What has been their experience of taking these drugs? To gain a deeper insight, in addition, you might also wish to interview a relevant health professional e.g. pharmacist, clinical nurse specialist, or rheumatologist. In the reflective component, describe what you have learned about the impact of a chronic disease such as RA/SpA and how modern treatments have affected this impact.

Suggested time allocation:


Weeks 1 & 2 Review the pathology of RA and/or SpA from lecture notes, and research the principles of modern management of these conditions. Research the new biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs), how they work, what they cost, what potential side-effects can occur, and the process by which these drugs can be prescribed to Australian patients. There are many journal articles on Medline. Refer also to: http://www.pbs.gov.au/html/home http://www.medicareaustralia.gov.au/provider/pbs/highly-specialised-drugs/index.jsp http://www.arthritisaustralia.com.au/ Ageing & Endings A Student Guide Session 2: TP4 2011 Page 63

Weeks 3 & 4 Week 5

Contact Professor Patrick McNeil (p.mcneil@unsw.edu.au) who will provide you with the name of a patient who is taking one of these drugs. Contact the patient to set up a time to interview them by phone or in person. Interview the patient who is taking one of the biological drugs and learn how it has affected their experience of their arthritis. Begin writing the report. Complete and submit the report.

Report requirements:
2,000 word report. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Social and cultural aspects of health and disease Provides a well-researched discussion of how Australian patients gain access to new expensive treatments. Focus Capability: Patient assessment and management Provides an appropriate analysis of the current management of RA and SpA and the place of new biological therapies for RA, their effectiveness, potential problems and a cost-benefit analysis. Adequately addresses the questions outlined in the Assignment tasks section and provides evidence of an appropriate interview with a patient taking a biological therapy for RA (transcript of interview NOT required). The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide.

Contact:
A discussion regarding this assignment is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 64

Assignment 2: Skin Cancer: Educating the Public


Note this assignment has a quota of 25 students. Please register your interest in this assignment by 9.00 am on the Monday of week 2.

Graduate Capabilities assessed in this assignment:


Using Basic and Clinical Sciences Effective Communication

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Aims:
To develop an audio or audiovisual guide that can be made available (via MP3 players) to lay visitors to the Museum of Human disease, and that uses specimens in the Museum to illustrate the natural history of common skin cancers.

Course themes and related learning activities:


This assignment relates to the course theme of Degenerative disease.

Task description and time allocation guide:


1. First understand the nature of the end product. You will produce an audio or audiovisual guide in a format suitable for playing on an MP3 player (iPod or equivalent). The audio guide will allow visitors to undertake a self-paced tour of specimens within the museum (say 5-10, but up to you) that will be of 15-30 mins duration. During that tour, the visitor will be directed to, and learn about, the various selected specimens. They will learn about their appearance, and they will learn about the effects that that disease had on the individual concerned (you may use some discretion here in describing a common clinical story). They will learn about the role of genetic and environmental risk factors in the disease process. Ideally, the visitor will see the tour as a coherent whole, and will leave with an improved understanding of the nature of melanoma and non-pigmented skin cancers, and their effects. The resource should provide a relevant, informative, interesting and accessible introduction to the topic of skin cancer, including premalignant lesions, diagnosis, natural history and complications. For the purposes of this assignment, the target audience of lay visitors means adults (20-80 years of age) with secondary school levels of English comprehension skills, but little specific knowledge of medical or biomedical concepts or terminology. Consider the various specimens available within the Museum of Human Disease that illustrate skin cancers and their complications, and are also of interest to the lay public. Through work in the course and through your background research, identify the key elements of information about each specimen and the disorders they represent that you think are important to convey to the lay audience. When you are ready, develop an audio or audiovisual file that can be used as the basis of the tour. The file should convey all relevant information to the lay visitor, and should be self-contained to the extent that the visitor will be able to complete the tour without having to ask questions or seek instruction from Museum staff. The audio file should be in MP3 format. Recording quality audio is a difficult process, and you will not be judged on this aspect of the work. Prepare a separate 1,000 word report that justifies your selection of the information and specimens that you have included in your MP3 file. The report should also indicate, where appropriate, how you believe the resource could be further improved. In addition to responding to the task requirements, you should reflect in your report on any particular issues that have arisen for you in doing this assignment. Review specimens and read generally on the topic of skin cancer and associated premalignant lesions. Identify relevant specimens from the Museum of Human Disease. Give careful thought to the sequence of events that might relate individual specimens to each other, and try to link specimens by telling a story about these relationships.

2.

3. 4.

5.

6. 7.

Suggested time allocation:


Weeks 1 & 2

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 65

Weeks 3 & 4 Week 5

Construct your audio or audiovisual file. Where possible, include colleagues and lay individuals in an initial evaluation. Refine the file and write the report. Submit both the report and the resource to eMed by the specified date.

Report requirements:
1,000 word report, plus MP3 file. The report should present: A justification of the information and specimens you included in the MP3 file; An indication of how the resource could be further improved; Reflections on what you learned by doing this project and on the issues encountered. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required) You should use standard UNSW Medicine referencing for your written report. However, it is not necessary to reference the learning resource.

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Using Basic and Clinical Sciences: Chooses specimens that allow an effective discussion of the natural history and complications of melanoma and non-pigmented skin cancers. Through materials presented in the audio or audiovisual file, as well as the written report, demonstrates an understanding of the relationship between the chosen specimens, as well as the causes, natural history and complications of the disease processes they represent. Relates the macroscopic appearances of tissues affected by skin cancer to the underlying disease process, and to the clinical manifestations of skin cancer. Focus Capability: Effective Communication Produces an MP3 file or equivalent that would allow a typical lay museum visitor to understand materials shown within the Museum of Human Disease without the need to consult staff or volunteers. Through use of text, voice and image, provides a description of relevant disease processes that would be clear and accessible to the lay Museum visitor. Uses sequencing of specimens and/or other methods to effectively convey the relationships between common skin cancers. The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide.

References:
Kumar, V., Abbas, A.K., Fausto, N. and Mitchell, R.N. (2007). Robbins' Basic Pathology (8th ed., pp. 173 185, 217-224.). Philadelphia, PA: Elsevier Saunders. Images of Disease CD Version 2.0, UNSW.

Contact:
A discussion regarding this assignment is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 66

Assignment 3: Communication Assignment Interview around a Theme from Ageing and Endings A
There is a quota of 80 students for this assignment. Please register your interest in this assignment by 9.00 am on the Monday of week 2. Follow instructions in the introduction to this section to register your interest in doing this assignment. If you have already completed this assignment and received a P-; P or P+ for the focus capabilities do not register for this assignment again as you will not be permitted to do this assignment. Please refer to Guidelines for Repeating the Phase 1 Communication Assignment for some advice in relation to repeating this assignment. http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/CommAssignmentP1?open&login

Capabilities assessed in this assignment:


Effective Communication Development as a Reflective Practitioner

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Introduction and aims:


The purposes of this assignment are: 1. To conduct a patient centred interview. A patient centred interview means to allow and encourage the other person to tell their story in their own words at their own pace. This is not an interview which focuses on the biomedical issues only. You should demonstrate your ability to understand the issue (both content and emotional components) from the interviewees perspective. The topic that you discuss must be something of significance for the interviewee so that you are able to explore their personal responses to the topic at more than a superficial, descriptive level. 2. To develop an ability to evaluate your own interviewing skills.

Course themes and related learning activities:


This assignment relates to the course themes of Ageing and Endings A. Please do not interpret this: I need to find a patient who has a health problem that we covered in Ageing and Endings A! Think broadly and consider the wide range of issues that relate to the course themes. Always ensure that your interviewee has a strong personal perspective on whatever you discuss the success of the assignment depends on the issue being important to that person. There are FAQs available in the discussion section for assignments within Blackboard. We have received many complaints from the hospital staff where students are requesting assistance from staff to find a suitable interviewee. Please do not approach staff for assistance and do not interview patients in hospital. Do not interview any person who: Has done an interview for another student Is under 18 years of age Has a mental illness, current drug/alcohol problem, eating disorder

Task description and time allocation guide:


1. Organise to interview one other person around a topic related to a theme in this course. The issue or topic must be significant and meaningful to that person. To give you the best opportunity to showcase the broad range of communication skills required by this assignment, select a subject who is currently, or who has personally, faced an issue related to this course. Selecting a subject who will just speak about an issue such as playing a sport/ having a hobby or something without significant emotional aspects is unlikely to give you this scope.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 67

It must be your first interview with that person. That means you should not rehearse or discuss the details of questions prior to taping the interview. The assignment requires you to demonstrate how you would deal with the issues raised by the interviewee in a spontaneous manner. The interview may not be with a member of your family, a close friend, another medical student, or any person under 18 years old. You should demonstrate your ability to understand another person from that person's point of view (content and emotional aspects). An interview of 10 minutes is adequate; 20 minutes is the maximum. Please note: a. It is not appropriate to pick the topic and find someone to interview. Rather you should negotiate the topic with a person willing to be interviewed. b. This is not a bio-medical interview, so do not interview to simply describe the medical history of the interviewee. However, your interview could include the experience your subject has had with medical and other health practitioners, their experience of their health issue, challenges they have faced and other relevant health issues. c. Do not interview hospital patients. Interviewing a patient in a public ward is often ineffective because of interruptions during the interview and more importantly the setting is not private. d. Generally, you should not approach medical and nursing staff you meet in clinical settings to be the subject of this interview, as they are unlikely to have the time for this role. e. Please do not ask any of your facilitators, clinical teachers or other tutors to either help you find a suitable person or be the interviewee. It is likely that they aware of the requirements for the assignments and that would make it unfair. 2. Make an audio version (i.e. either an ordinary full size cassette, mini tape or an audio CD ROM playable on a standard CD player) of this interview. It must be clearly audible. The discussion may not be scripted and the tape/CD may not be edited. The audio recording must not be stopped at any point throughout the discussion. You will be required to demonstrate that you can: Actively listened to and reflect content, feelings and significant non-verbal communication in the interview. Gain an understanding of the interviewees perspective. Show respect, caring and confidentiality in your relationship with the person. Show that you are "following" the person. Manage the time constraints. Make a transcript of the interview. This transcript is an accurate word-for-word account. It should include a description of significant non-verbal responses of the interviewer and the other person. Number each of your own responses consecutively. Write the actual duration of the interview at the start of the transcript. For the written report you will be required to: a) Choose your three most effective responses. Explain how each was effective. b) Choose your three least effective responses. Explain why they were not so effective. Write a more effective response in each case, word for word as you might have said it. You could also include descriptions of nonverbal behaviour you would use with these more effective responses.

3.

4.

5.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 68

c)

Evaluate your success in managing the interview. You may like to use the following as a guide for this. Remember this list is not exhaustive and other individual issues may arise in your particular interview. 1. How you managed the interview as a whole. 2. What parts of the interview went well. 3. What parts were more difficult and why they felt more difficult. 4. Any issues that arose during the interview that you had not anticipated or were surprised about. 5. The effectiveness of the beginning of the interview. 6. The effectiveness of the end of the interview. 7. Your management of time in the interview. 8. How you demonstrated respect, caring and confidentiality.

6.

Integrate ideas from your wider reading about the impact of effective communication within the doctor-patient relationship and discuss how the ideas discussed influenced your evaluation of this interview. Confidentiality Be sure to keep strict confidentiality: Ensure that the person's name is not visible on the outside of the written assignment or on the audio version. You are required to give provide (discreetly, and keeping confidentiality) the name, telephone number and address of the person you interview. You can do this by placing the information in a sealed envelope and hand it in with the audio version. You may assure the person that the only people to have access to the interview are you and staff involved in the marking of the assignment.

7.

Some Tips for a Successful Interview 1. Establishing the Purpose of the Interview This should be from the person's point of view, not yours. For the assignment this should be established before the tape is commenced but reiterated on tape, e.g. "Now, what is it that you would like to talk about?" or "Perhaps you could tell me again what you'd like to talk about", said in a warm manner, and addressed to the person, not a listener. You should not have a detailed plan of the questions or issues that you are going to cover. Suitable topics or issues to discuss with your interviewee need to be significant and meaningful to the person. The topic should not be trivial. It should not be just academic or intellectual. Good interviews include the personal reactions and emotional issues that the interviewee needed to deal with in relation to the topic i.e. the patient perspective. 2. Keep the interview going, "following" the person This is the exploratory stage of the 'open interview'. The person should be encouraged to express their initial ideas and feelings. The interviewer should build rapport and help the person explore the issue.

Time allocation guide:


Week 2 Week 3 Week 4 -5 Decide on interviewee and negotiate a topic Conduct interview Prepare transcription and write report

Report requirements:
1,500 2,000 words report, not including the transcript. You will need to submit both the report and transcript online and provide the audio recording with the details of the interviewee to the Medicine Education and Student Office (Level 2, AGSM Building). Please include the report and transcript in the one document. The eMed receipt number of your assignment must be clearly marked on the CD/tape (i.e. you must submit the assignment before you hand in the audio recording).

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 69

You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Effective Communication Uses effective communication skills to elicit the persons story. Demonstrates an understanding of the persons experiences. This should include an understanding of the physical as well as any psychosocial issues involved. Analyses the issues that have affected the interviewees ideas about the topic. Focus Capability: Development of a Reflective Practitioner Evaluate those communication/interviewing skills that were used effectively. Discuss any communication or other difficulties you had during the interviews, and the attempts to resolve them. Discuss how your reading about effective communication in the doctor-patient relationship influenced your evaluation of this interview. Discusses any feelings and reactions you had to the person, the story, or the report. The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide. Development as a Reflective Practitioner (the generic capability) requires you to consider your learning and development beyond this one interview. You are required to reflect much more widely on your own development as a practitioner, your challenges with various communication skills, experiences of different interactions with different patients, what youre learning about yourself in these different contexts, how you are trying to apply these skills in a number of contexts and other related self awareness, learning and development.

References:
If you need a letter of introduction please contact Edna Koritschoner by email e.koritschoner@unsw.edu.au You should draw on the learning activities from the Clinical Skills sessions. Silverman, J., Kurtz, S. and Draper, J. (2005). Skills for Communicating with Patients (2nd ed.). Abingdon, Oxon, UK; New York: Radcliffe Medical Press. Illingworth, R. (2010). What does patient centred mean in relation to the consultation? The Clinical Teacher, 7(2), 116-120. http://sirius.library.unsw.edu.au:9003/sfx_local?issn=1743498X&date=2010&volume=7&issue=2&spage=116

Contact:
A discussion regarding this assignment is available through Blackboard Discussions Please read the FAQs provided there before posting a question.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 70

Assignment 4: Developing a Science-based Ageing and Endings A Wiki Entry


Note this assignment has a quota of 20 students. Please register your interest in this assignment by 9.00 am on the Monday of week 2.

Graduate Capabilities assessed in this assignment:


Using Basic and Clinical Sciences Development as aReflective Practitioner

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Aims:
The aim of this assignment is to give you the opportunity to deepen your understanding of basic and clinic sciences and develop reflection skills by researching a topic related to Ageing and Endings A scenarios and then translating your research into a Wikipedia-style entry for use as a learning resource for your peers. This wiki entry should contain sound content and cover the topic adequately. It should also aim to teach at a peer level using your own innovative diagrams, interesting examples and explanations. The wiki will be available to your peers, who will be able to edit and comment (http://www.unsw.wikispaces.net/). The final wiki entry following this process is submitted as the report and will include a reflection on the peer-feedback and editing process. All entries will be retained on a public (to students and staff) wiki site and will continue to be viewed, edited and maintained according to standard wiki etiquette. The UNSW eMedWIki site can be accessed in the BlackBoard course under General Resources.

Course themes and related learning activities:


Based on a topic allocated to you from a list of topics taken from the scenarios in the course that relates to the Using Basic and Clinical Sciences capability.

Task description and time allocation guide:


1. 2. Register for the assignment at the end of the first week as a quota is in place (20 students). If you are selected within the quota, you will be assigned a topic from the list supplied below. Most topics will be at least partially addressed in activities before week 4. You will also be allocated another topic for you to comment/edit in week 5. Begin by doing a comprehensive literature search and as you read, jot down potential headings for your wiki and points where you think that you need to include more information, explanation or detail to explain it fully to a peer. These troublesome spots are probably concepts that you and your colleagues find more difficult than others, or which contain troublesome (i.e. new or complex) language (or terminology). The best wikis are those that explain the content better. You should give more than an overview of your topic and more than what is covered in lectures. Your wiki should complement the structured learning activities by expanding on some relevant or interesting area (using sub-headings) and/or by describing/explaining some troublesome content. Your wiki should relate the content to the specific scenarios in Ageing and Endings A and the main learning aims of these scenarios. Decide on your wiki headings and begin to write 1,500 words on your chosen topic. You will be sent instructions on how to use the wiki software after you have been selected for this assignment. Direct the level of the wiki to a readership of your peers in Phase 1 of the UNSW Medicine program. Use innovative figures/tables/diagrams/explanations to illustrate the content with the aim of increasing the understanding of your peers, the readers. All of the wikis will be opened up to editing by your peers in Phase 1 on the Friday of week 4. During week 5 you should monitor the edits made by your peers to your wiki, taking notes to use later in your reflection. You should also be involved in the talk discussions that may follow editing of your wiki where someone makes further comments or explanations about why they made their edits. During week 5 you should also review and edit an eMedWiki entry developed by a peer on another topic relating to the scenarios in the course (and as allocated to you). By the end of week 5 you need to have reviewed all the edits made to your wiki and reflect on the changes made by your peers. Write a Reflection section (500 words) that includes specific mention of the wiki writing and editing process plus a more generic reflection on the project in terms of what you learnt Ageing & Endings A Student Guide Session 2: TP4 2011 Page 71

3.

4.

5.

6. 7.

8. 9.

overall. Download (e.g. by copying and pasting) all of the edits linked together with their associated discussion entries made in the exposed wiki in the edit time period. Attach this to your report as supplementary material. You should also reflect on the process of reviewing a peers wiki. 10. Submit your final wiki version (final meaning the version on the wiki site at the end of week 5, copied and pasted into a Word doc) and the Reflection section plus the supplementary material via eMed as usual.

Wiki topics:
If you are selected within the quota for this assignment you will be allocated one of the following topics. The topics are quite general and your wiki is expected to supplement formal learning activities. Hence you need to go beyond what has been taught in formal learning activities, while relating the content back to the scenarios. You may concentrate on more specific aspects within these topics, but you should justify why you choose to concentrate on that subheading.

Topic List:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Pathophysiology of diabetic neuropathy Chemotherapy and peripheral neuropathy Physiological basis for neural impulse conduction Nerve conduction studies for diagnosis of carpal tunnel syndrome Diagnosis and staging of lung cancer Obesity and cancer Cauda equina syndromes Compartment syndromes of the lower limb Infective arthritis Pathophysiology of gout Avascular necrosis of the head of the femur Rotator cuff injuries Prevention of osteoporosis Glucocorticoids and osteoporosis Neurophysiology of nausea in cancer patients Vesibular pathways CNS areas receiving vestibular inputs and their function Physiological basis of the perception of pain originating within bone Brachial neuritis clinical features, treatment and prognosis Paraneoplastic syndromes New advances in cancer chemotherapy using antibodies. Begin research on your topic and headings. Write and format the wiki using APA-style citation and reference list. Wikis go open to editing. Monitor the edits as they appear during this week; write notes and reflect on the suggestions and consider how the wiki may have been improved. Edit the wiki of a peers topic as allocated. Write the Reflection section. Submit the final wiki version and the Reflection section plus the supplementary material via eMed by the deadline.

Suggested time allocation:


Week 2 Week 3 End of Wk 4 Week 5

Report requirements:
The report should be a maximum of 2,000 words, including at least 500 words in the Reflection section, plus the supplementary material. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 72

Instructions for wiki etiquette and wiki formatting and posting:


Instructions on how to access and use the wiki software will be sent to students selected into the quota for this assignment. Development and editing of wiki entries should be conducted in general accordance with the guidelines for Wikipedia at: http://en.wikipedia.org/wiki/Wikipedia:Etiquette. Failure to follow these guidelines may result in a downgrading of the grade for generic effective communication.

Plagiarism and copyright issues:


All material in the wiki should be your own writing. Any information or images sourced from elsewhere must be cited and referenced adequately. Copyrighted images must be checked to see whether they may be used in an academic forum. If not, then they cannot be used. This is your chance to make your own images, tables, lists, graphs and charts (but please cite the sources of all evidence used to produce these) and it is suggested that you initial and date these to show that they were produced by you. A cautionary note: Markers will be well aware of any Wikipedia and other wiki entries available on these topics and will readily identify students who plagiarise directly from them. See the material available at the beginning of this section on plagiarism for information on definitions and penalties.

References:
Should follow one style and be consistent. Suggested style is superscript numbered citation with APA style references in a list at the end of the wiki.

Assessment criteria:
For a P grade, the written report should meet the following criteria: Focus Capability: Using Basic and Clinical Sciences The key points relating to the topic that you were allocated are clearly described. The choice of content, headings and sub-headings, diagrams, tables, graphs etc show a good understanding of the topic area. The wiki has an element of teaching at a peer level using the students own innovative diagrams, tables or figures and/or using interesting examples or explanations. Evidence of significant research relating to basic and clinical sciences that goes beyond the formal teaching activities. Focus Capability: Development as a Reflective Practitioner Relates the topics and content of the wiki entry to learning aims and scenario of A&E A. Clearly reflects on editing/feedback from peers and articulates how the wiki could be improved (or not) based on peer comments/feedback. Demonstrates an ability to review his/her own work when criticised in an open edited wiki format. Reflects on what was learned from the process of editing a peers wiki. Evaluates own performance and that of editing peers to give a rounded summary of this wiki process in terms of personal effort and achievement, the performance of the wiki community and the wider implications of setting up a UNSW Phase 1 Med Wiki. The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide. For the Wiki Assignment the Self-directed Learning and Critical Evaluation generic criteria will also include the following points: The content of the wiki should demonstrate to the reader that you have researched adequately on this topic and covered the key areas necessary to inform your peers in their learning. Develops and edits the wiki entries in accordance with the Wikipedia guidelines.

Contact:
A discussion regarding this assignment is available through Blackboard Discussions. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 73

Assignment 5: To Screen or Not to Screen? Carcinoma of the Prostate


Graduate capabilities assessed in this assignment:
Social and Cultural Aspects of Health and Disease Self-directed Learning and Critical Evaluation

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Aims:
To describe the screening principles behind the detection of carcinoma of the prostate and evaluate the evidence regarding the effectiveness of digital rectal examination and PSA testing in screening for this disease. This will involve a full literature search and formal evaluation of evidence found.

Course themes and related learning activities:


This assignment relates to the course theme: Living with cancer. It also relates to the Quality of Medical Practice element (QMP) topic area of critical appraisal, as well as the public health principles underpinning screening.

Task description and time allocation guide:


Research the epidemiology and the pathology of carcinoma of the prostate, the symptoms and signs of this disease and the major diagnostic tests. Read the WHO Principles of Screening. Use what you have learned of these elements to write a coherent introduction to the assignment topic and the question posed. Carry out a full literature search into the efficacy of using digital rectal examination and the PSA test to screen for prostate cancer in clinically well men. Record your search strategy and its results in a table and append to your submission. Evaluate the key pieces of literature found in your literature search using the 'CRAAP' or similar basic evaluative process and record this in the appendix. Choose one article from your search that reports on an important, high quality, high level clinical trial and carry out a full critical appraisal on the study using the QMP critical appraisal sheet (see below). Using the best and most relevant of the evaluated evidence, write a critical discussion regarding the evidence for and against the use of digital rectal examination and PSA in screening for prostate cancer in well men, using the WHO screening criteria as your standard. Write a conclusion regarding whether either or both of these tests should be used to screen for prostate cancer in well men in Australia.

Report requirements:
2,000 word report, including appropriate illustrations, graphs etc. Students are encouraged to use tabular presentation to summarise clinical features, investigations and therapeutic interventions, where appropriate. However, these should not replace lucid, carefully composed prose. The appendix should include a full summary of the literature search for the effectiveness of the tests with the basic evaluation of the important findings and the full QMP worksheet for the chosen trial. You should include in your report a reflection on what you have learned from this assignment and how it will influence your future clinical practice. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 74

Assessment criteria:
For a P grade, the written report should meet the following criteria: Focus Capability: Social and cultural aspects of health and disease Briefly describes the epidemiology and pathology of carcinoma of the prostate, its symptoms and signs and the major diagnostic tests currently used in Australia. Also introduces the WHO screening criteria. Using the WHO Screening Criteria, critically discusses the evidence for the use of digital rectal examination and PSA in screening for prostate cancer in well men in Australia. Draws a sensible conclusion based on the available evidence regarding whether prostate cancer should be screened for in Australia using digital rectal examination and the PSA test. Focus Capability: Self-directed learning and critical evaluation Conducts a thorough literature search to find the best evidence to answer the key question. This search is fully documented and appended in a simple table. Carefully evaluates the best of the evidence found in the above search. Completes and appends a full and clear critical appraisal of the best study /article using the QMP CA Multi-use worksheet 8 point version. Uses this appraisal of the evidence to discuss clearly the current best evidence available on the use of digital rectal examination and PSA in screening for prostate cancer in well men in Australia. The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide.

Contact:
A discussion regarding this assignment is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 75

Assignment 6: Euthanasia and Ethics


IMPORTANT NOTE: This is an exercise in academic research of the issues surrounding the ethics of euthanasia. You do not need to interview palliative care or other specialists in the area.
Graduate capabilities assessed in this assignment:
Understanding ethics and legal responsibility Social and cultural aspects of health and disease

The report will also be assessed for each of the generic capabilities for assignments (Effective communication, Self-directed learning and critical evaluation and Development as a reflective practitioner).

Aims:
This assignment asks you to investigate the notion of euthanasia and the moral arguments both for and against it. You will also be required to investigate some of the social and cultural attitudes towards euthanasia and the resultant legislation that have been set up in some countries to allow it.

Course themes and related learning activities:


This assignment relates to the course theme of Death and dying.

Task description and time allocation guide:


1. One of the major difficulties in discussions about euthanasia is the confusion over terminology. Define and discuss the differences between the terms: active euthanasia; passive euthanasia; mercy killing; physician-assisted suicide; and the principle of double effect. Explain what legislation exists in relation to these terms both in Australia and in one overseas example (where legislation is different). What are some of the practical implications of Australian legislation for medical practice? Investigate some of the practical and moral arguments both for and against euthanasia. Be sure to refer to some of the contemporary bioethicists, such as James Rachels, Daniel Callaghan and Peter Singer, who have written on this topic, as well as the medical literature (and the ethics textbook which has an excellent section on euthanasia). In this section of your report you should also discuss some of the cultural, religious and social issues that affect the discussion of euthanasia. After reading about the practical and moral arguments for and against euthanasia, think about it and discuss your conclusion about whether or not it should be legal in Australia.

2.

3.

Suggested time allocation:


Weeks 1 & 2 Gain an understanding of the related terms and research the topic. Weeks 3 Research the topic. Weeks 4 Complete report, including reflection.

Report requirements:
2,000 word report. In addition to responding to the task questions, you should reflect on your own views on euthanasia and whether they have been affected or changed by completing the above tasks. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 76

Assessment criteria:
For a P grade, the written report should meet the following criteria: Focus Capability: Understanding ethics and legal responsibility Defines terms mentioned in the task description appropriately and discusses the practical application of these terms in medicine. Explores relevant legislation in Australia and one other country. Discusses moral arguments for and against euthanasia, with reference to relevant literature. Reflects on their own opinion regarding euthanasia and whether the process of completing this assignment has affected their opinion in any way. Focus Capability: Social and cultural aspects of health and disease Discusses the social and cultural factors that affect the acceptance or rejection of euthanasia. Discusses the stance of some religious and medical bodies (such as the AMA) in relation to euthanasia. The generic capabilities (Effective communication, Self direction and critical evaluation and development as a reflective practitioner) will be assessed using the generic criteria listed in the Program guide. .

References
Kerridge, I, Lowe M, McPhee J. (2005) Ethics and law for the health profession. (2nd ed.) Federation Press. Singer, P. (1993) Practical ethics. 2nd edition, Cambridge University Press.

Contact:
A discussion regarding this assignment is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 77

Project 1: The Knee in Health and Disease


This project would be suitable for groups of 4-6 students.

Graduate capabilities assessed in this project:


Using Basic and Clinical Sciences Patient Assessment and Management

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
To explain the biomechanics of the normal knee and consider how knee injury during early life may predispose to later disease. To outline the design principles behind modern knee prostheses. To discuss the indications for knee replacement surgery. To outline the post-operative management and possible complications for individuals who have undergone knee replacement surgery. To briefly examine the reasons for failure of knee prostheses.

Course themes and related learning activities:


This project relates to the course theme: the degenerative process.

Task description and time allocation guide:


Task 1: Research the biomechanics of the normal knee using textbooks, recent review articles and significant recent original articles in quality peer-reviewed journals. Task 2: Consider how sporting injuries in early life may predispose to the later development of degenerative disease in the knee. Task 3: Investigate the principles behind the design of knee prostheses and the indications for knee replacement surgery. Task 4: Explore the post-operative management and possible complications for individuals who have undergone knee replacement surgery and the reasons for failure of knee prostheses.

Report requirements:
Maximum 2,500 word report including appropriate illustrations of knee anatomy and biomechanics, and of knee prostheses. The report should also include tabular presentation of patient management principles and guidelines, as well as data on the complications of prosthesis surgery and the reasons for prosthesis failure. NOTE: Your consideration of normal knee biomechanics must go beyond a simple consideration of knee anatomy. You must also discuss the functional anatomy of the knee ligaments, menisci and joint surfaces during normal activity. How does injury to the cruciate ligaments and/or menisci during adolescence or young adulthood cause instability in the knee and predispose to the development of knee disease in later life? You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 78

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Using basic and clinical sciences Describes and illustrates the biomechanics of the normal knee. Explains how injury in late adolescence or early adulthood may alter the biomechanics of the knee and predispose to osteoarthritis. Demonstrates an understanding of the design principles behind knee prostheses. Focus Capability: Patient assessment and management Describes the indications for knee replacement surgery. Outlines the principles of post-operative management of knee replacement recipients and the possible complications of surgery. Discusses reasons for the failure of knee prostheses. The above components will be equally weighted in the assessment and should be given equal coverage in the report. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide.

References:
Block, J.A. and Shakoor, N. (2010) Lower limb osteoarthritis: biomechanical alterations and implications for therapy. Current Opinions in Rheumatology. Sept 22(5):544-550. Englund, M. (2010) The role of biomechanics in the initiation and progression of OA of the knee. Best Pract Res Clin Rheumatol. Feb 24(1):39-46. Flandry, F. and Hommel, G. (2011) Normal anatomy and biomechanics of the knee. Sports Medicine & Arthroscopy Review. June 19(2):82-92. Hunter, D.J. and Wilson, D.R. (2009) Role of alignment and biomechanics in osteoarthritis and implications for imaging. Radiol Clin North America. July 47(4):553-566. Pandy, M.G. and Andriacchi, T.P. (2010) Muscle and joint function in human locomotion. Annual Revue of Biomedical Engineering 12:401-433. Wilson, D.R., McWalter, E.J. and Johnston, J.D. (2008) The measurement of joint mechanics and their role in osteoarthritis genesis and progression. Rheum Dis Clin North America. Jan 34(3):605-622.

Contact:
A discussion regarding this project is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 79

Project 2: Polypharmacy and Falls in the Elderly


This project would be suitable for groups of 4-5 students.

Graduate capabilities assessed in this project:


Using Basic and Clinical Sciences Social and Cultural aspects of health and disease

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
Many of Australias elders are taking multiple medications for chronic conditions. Polypharmacy (the use of five or more drugs) is relatively common, and some studies suggest that it may be an independent risk factor for falls in the elderly. The aims of this project are to: Outline the problem of increased risk of falls (and thus fractures) associated with polypharmacy in the elderly. Identify physiological changes occurring in the elderly that effect drug therapy (e.g. pharmacokinetics, pharmacodynamics, cognitive impairment) and the risk of fractures. Compare the evidence that polypharmacy or the particular side-effects of specific drug classes (e.g. anti-hypertensives, psychotropics) are more likely to increase the incidence of falls in the elderly. To identify potential strategies to minimise problems arising from polypharmacy (and thus increased risk of falls and fractures) in the elderly. Develop an educational resource that should assist general practitioners in educating family and carers of elders about optimal use of medicines.

Course themes and related learning activities:


This project relates to the course theme: The ageing process

Task description and time allocation guide:


Task 1: Search for information on polypharmacy and risk of falls (and fractures) in the elderly. Identify the physiological changes that occur in the elderly that can have an impact on drug therapy (e.g. pharmacokinetics, pharmacodynamics, cognitive impairment) and increase the risk of fractures. Task 2: Choose two different drug classes that are known to be commonly used in the elderly and compare how the use of these drug classes may increase the risk of falls. Discuss whether polypharmacy itself or these specific drug classes are more likely to result in a fall. Task 3: Discuss the impact that an increased risk of falls may have on elders. Describe current strategies devise some of your own for minimising problems associated with polypharmacy (and thus increased risk of falls and fractures) in elders. Task 4: Develop an educational resource (short pamphlet 150 to 250 words) that could assist general practitioners in educating family and carers of elderly patients about optimal use of medicines. Suggested time allocation: Weeks 1 to 2 Research polypharmacy and the risk of falls in elders. Weeks 3 to 4 Research two different drug classes known to be commonly used in elders and compare the mechanisms by which the use of these drug classes in elders may increase the risk of falls. Weeks 5 to 6 Finalise research, write report and develop an educational resource.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 80

Report requirements: Maximum 2,500 words report (including educational resource). You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required) Assessment criteria: For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Using Basic and Clinical Sciences Provides an appropriate analysis of the potential problems of polypharmacy in elders and increased risk of falls (and fractures). Provides an overview of the physiological changes occurring in elders that underlie the problems of polypharmacy (e.g. pharmacokinetics, pharmacodynamics, cognitive impairment etc.) and increase risk of falls (and fractures). Provides a well-researched discussion on minimising the harm cause by polypharmacy. Focus Capability: Social and Cultural aspects of health and disease Describes and discusses the impact that an increased risk of falls may have on elders, their families and the health care system. Provides an overview of current and potential strategies that can be used to overcome some of the obstacles associated with polypharmacy in elders. Develops an educational resource that can aid health professionals in helping patients and their families. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide.

Some starting references:


1. Wilson, N.M., Hilmer, S.N., March, L.M., Cameron, I.D., Lord, S.R., Seibel, M.J., Mason, R.S., Chen, J.S., Cumming, R.G. and Sambrook, P.N. (2011) Associations between drug burden index and falls in older people in residential aged care. J Am Geriatr Soc. 59(5):875-80. http://www.ncbi.nlm.nih.gov/pubmed/21539525 Woolcott, J.C., Richardson, K.J., Wiens, M.O., Patel, B., Marin, J., Khan, K.M. and Marra, C.A. (2009) Metaanalysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 169(21):195260. http://www.ncbi.nlm.nih.gov/pubmed/19933955 Beer, C., Hyde, Z., Almeida, O.P., Norman, P., Hankey, G.J., Yeap, B.B. and Flicker, L. (2011) Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study. Br J Clin Pharmacol. 71(4):592-9. http://www.ncbi.nlm.nih.gov/pubmed/21395652 Baranzini, F., Diurni, M., Ceccon, F., Poloni, N., Cazzamalli, S., Costantini, C., Colli, C., Greco, L. and Callegari, C. (2009) Fall-related injuries in a nursing home setting: is polypharmacy a risk factor? BMC Health Serv Res. 9:228. http://www.ncbi.nlm.nih.gov/pubmed/20003327

2.

3.

4.

Contact:
A discussion regarding this project is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 81

Project 3: Primary Brain Tumours in Adults


This project is suitable for a group of 4 students.

Graduate Capabilities assessed in this project:


Patient Assessment and Management Self-Directed Learning and Critical Evaluation

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Introduction:
Brain tumours can affect both younger and older individuals and do not have many known causative factors. Hence, there are no preventive, screening or routine management strategies available. They contribute to significant morbidity, functional and psychological disability and frequently, mortality. Although they comprise only a small proportion of all cancers, both the disease and its management (both interventional and noninterventional) can significantly affect a multitude of patients.

Aims:
To describe histopathology, morphology, clinical features and treatment of GBM (glioblastoma multiforme). To explore the possible causative factors, including genetic factors associated with brain tumours. To understand the role of specialist involvement and the options for treatment (surgeons, radiation oncologists, medical oncologists). To explore the goals of treatment, focusing on quality of life, general well-being, daily functioning, personal and social interactions, nutrition, symptom control. To appreciate the requirement for multidisciplinary care with appropriate involvement of allied health staff including physiotherapists, occupational therapists, social workers, psychologists and clinical nurse specialists.

Course themes and related learning activities:


This project relates to the course themes: The degenerative process.

Task description and time allocation guide:


The task is to research and write a report on the commonest primary brain tumours. Task 1 Task 2 Task 3 Search for clinical information on GBM. Briefly outline the pathology. Describe the presenting symptoms and signs. Discuss the known and postulated causative factors for GBM, including any genetic factors. Discuss the treatment modalities available for management of GBM including surgery, radiotherapy and chemotherapy, together with the relative advantages and drawbacks of each modality. Your discussion should include the role of these treatments when utilised individually, concurrently or sequentially. You only need to concentrate on drugs approved for treatment of these tumours in Australia. Discuss the role of multidisciplinary care of patients with GBM and outline the roles of allied health staff including physiotherapists, occupational therapists, social workers, psychologists and clinical nurse specialists. Have an initial meeting of team members to allocate tasks. Assign individual tasks according to strengths and interest. Gather information on the basic science of GBM. Begin to research treatment options and the workings of multidisciplinary care teams. Review progress with colleagues in the project team. Support team members who are facing difficulties. Allocate time according to aspects of the project still needing research. Prepare material for presentation to your Scenario Group. Write report. Reflect on feedback from peers. Finish writing and reviewing the report.

Task 4

Suggested time allocation:


Weeks 1 & 2:

Week 3: Week 4: Weeks 5 & 6:

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 82

Report requirements:
Maximum 2,500 word report You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Patient assessment and management Clearly summarises the common presenting features of GBM and how these affect patient assessment and management. Satisfactorily discusses fundamental principles of patient management including multidisciplinary care and defines the roles of various health professionals involved in care. Able to adequately discuss the interaction of psychological, functional and social factors in patient care. Focus Capability: Self-Directed Learning and Critical Evaluation Adequately researches the risk factors for, and pathology of, GBM. Satisfactorily discusses the pros and cons of various approaches to patient management and summarises relevant evidence from major clinical trials and meta-analyses of clinical data. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide. Suggested Initial References: 1) Abeloff. M.D., Armitage, J.O., Niederhuber, J.E., Kastan, M.B. and McKenna, W.G. (2008) CNS tumours in th Abeloffs Clinical Oncology. (4 ed. Chapter 70) Churchill Livingstone (available via MD consult) th 2) Kumar, V:, Abbas, A.K., Fausto,N., and Aster, J. (2010) Robbins & Cotran. Pathologic basis of disease, (8 ed., Chapter 28) Saunders (available via MD consult) 3) Dinnes, J. Cave, C. Huang, S. Major, K. Milne, R. (2001) The effectiveness and cost-effectiveness of temozolomide for the treatment of recurrent malignant glioma: a rapid and systematic review (Structured abstract). Health Technology Assessment Health Technology Assessment 2001; Vol.5: No. 13 http://www.hta.ac.uk/execsumm/summ513.htm 4) Stewart, L. and Burdett, S. (2002) Glioma Meta-analysis Trialsists Group (GMT). Chemotherapy for highgrade glioma. EBM Reviews Cochrane Database of Systematic Reviews. 2002 Issue 4. Art. No.: CD003913. DOI: 10.1002/14651858.CD003913. http://www2.cochrane.org/reviews/en/ab003913.html th 5) Asher, A. et al. (2004) A Primer of Brain Tumors, A patients reference manual (8 ed.) American Brain Tumour Association publication .http://www.abta.org/siteFiles/SitePages/E2E7B6E1D9BBEAD2103BCB9F2C80D588.pdf 6) Lavelle, P. (2008) Brain tumours. ABC Health & Wellbeing. Patient stories http://www.abc.net.au/health/library/stories/2008/04/22/2210840.htm

Contact:
A discussion regarding this project is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 83

Project 4: Revising key concepts of Phase 1 Medicine


Group size: 3 to 5 students, which MUST include a mix of first and second year students.

Graduate Capabilities assessed in this project:


Self-Directed Learning and Critical Evaluation Teamwork

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
1. Develop an integrated view of Phase 1 themes Clarify and understand key aspects of Phase 1 themes Prioritise the key learning areas that relate to each course Develop an understanding of the types of questions that require higher level thinking Develop collaborative learning and peer teaching skills using questions and model answers Consider all (9) Phase 1 courses and the scenarios within them. Identify content themes that relate to each of those courses and prioritise a set of key content themes that your group considers are crucial for understanding each course. From this list, prioritise 4-5 themes to focus on. Formulate a range of short answer and multiple choice questions (MCQs), which relate to the above key content themes. Discuss the questions within your project group and ensure that the questions: relate to key aspects of content learnt in Phase 1, with a balance between content covered in 2010 and 2011; require a higher level of thinking and not mere recall of information. (For example, better questions may require integration of content across disciplines, problem solving, application of content knowledge to new situations etc.); and cover a range of graduate capabilities that MUST include: Using Basic and Clinical Sciences, Patient Assessment and Management, Social and Cultural Aspects of Health and Disease, Ethics and Legal Responsibilities. As far as possible, ensure that the questions require answers that integrate knowledge across various disciplines and/or scenarios. Generate model answers for the questions. Include summary points to justify your answer. Conduct peer teaching within the wider scenario group (during weekly SGS sessions and during SGS 9) based on the content themes and the relevant questions. Seek feedback on the model answer, and clarify any areas that are unclear or contentious. Refine the AEA question and model answer and submit to eMed by 5pm on Friday in week 5. This submission process will be similar to submitting an assignment to eMed, and will be under the title Key concepts project Student generated questions. Document the process that you undertake to refine the model answers and to ensure the accuracy of answers (e.g. cite sources, discuss how you responded to queries on accuracy etc). Develop a mechanism to gather feedback on the effectiveness of your peer teaching (i.e. the usefulness of your questions and answers as a peer teaching activity).

Task description:

2.

3.

4. 5.

Report requirements:
Your report should include: 1. Your best 1-2 short answer questions and 1-2 MCQs, a discussion of why you believe these are your best questions, and a discussion of the model answers to these questions. Detailed model answers must be included as an appendix. The appendix must also include a selection of questions and answers developed. 2. An evaluation of the effectiveness of the peer teaching process based on the feedback from the scenario group. 3. A discussion of the process used to refine the questions and increase accuracy of information. 4. Your appendix should include a selection of the short answer and MCQ questions developed together with the model answers. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 84

The report should be a maximum of 2,500 words. Include a component evaluating your teamwork. Detailed model answers must be included as an appendix. Appendix should not exceed 10 pages (10pt font). You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Self-Directed Learning and Critical Evaluation Formulates a good range of short answer and multiple choice questions that relate to the four recommended capabilities. The questions are accompanied by a discussion of the model answers (within the report) and detailed model answers (in an appendix). Discusses reasons for choice of best questions for inclusion in the report. Discusses the model answers relevant to these questions, and discusses the process taken to ensure accuracy of information. Focus Capability: Teamwork Discusses how a collaborative approach helped refine and improve the model answers. Discusses the effectiveness of peer teaching based on feedback received from scenario group. Reflects on how a collaborative approach impacted on the quality of learning of the content addressed in this project. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide.

References:
UNSW Faculty of Medicine (2009). Writing multiple choice questions: A Manual for Staff in the Faculty of Medicine, UNSW http://medprogram.med.unsw.edu.au/Med3802Web.nsf/resources/ProgramGuide/$file/MCQ_Manual_0 9.pdf?open&login (UNSW Login required) Shumway, J.M. and R.M. Harden. (2003). Amee guide no. 25: The assessment of learning outcomes for the competent and reflective physician. Medical Teacher, 25 (6), 569 - 84. World Health Organization (2010). Topic 4: Being an effective team player. WHO Patient Safety Curriculum Guide. http://www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf Isaacs, G. (1996). Blooms taxonomy of educational objectives. Brisbane: Teaching and Educational Development Institute, University of Queensland. http://www.tedi.uq.edu.au/downloads/Bloom.pdf

Contact:
A discussion regarding this project is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 85

Project 5: Multiple Sclerosis


This project is suitable for a group of 4 students.

Graduate Capabilities assessed in this project:


Patient Assessment and Management Self-Directed Learning and Critical Evaluation

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
To develop your understanding of multiple sclerosis, which is the most significant non-traumatic cause of neurological disability in young adults. You will investigate recent studies that have examined the possible roles of viral aetiologies, vitamin D deficiency and sunlight exposure as contributing factors to the development of MS. You will also review the common presenting features of this condition and the benefits of multidisciplinary patient care.

Course themes and related learning activities:


This project relates to the course theme: Degenerative Diseases.

Task description and time allocation guide:


The task is to research and write a report on multiple sclerosis. Each task should be given equal weighting. You will need to show the search strategy used, problems encountered and results obtained using a table in an appendix. Task 1 Search for clinical information on multiple sclerosis. Briefly outline the pathology of the disease before discussing the clinical features of MS. Which parts of the nervous system does it affect and how does this relate to the clinical manifestations? Why are certain brain areas more likely to be affected in MS?

Task 2: Discuss the major current theories of causation that pertain to ethnicity, genetic factors and the possible role of geographic latitude in MS. Task 3: Discuss the data regarding the potential role of viruses, including Epstein-Barr virus in the development of MS. Also discuss the possible role of vitamin D deficiency in MS and whether this might play a role in the development of disease. Task 4: Discuss the ways in which MS can be treated. Your discussion should include the role of multidisciplinary care, in addition to an outline of the disease-modifying drugs available for MS. You will only need to focus on those disease-modifying drugs that are currently licensed for use in Australia. You will have to discuss their modes of action, clinical benefits and side-effect profiles.

Suggested time allocation:


Wk 1-2: Wk 3-4: Research background information on MS, current theories of causation and the role of the multidisciplinary team. Critically appraise and summarise the literature. Begin to assemble the report outlining the scientific issues and critically evaluate the relative merits and the potential flaws of each theory regarding MS causation. Finish writing and review the report.

Wk 5-6:

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Report requirements:
Maximum 2,500 word report. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Patient assessment and management Clearly describes the epidemiology and pathology of MS and clearly outlines the major presenting features of MS. Adequately discusses basic principles of patient management in MS, including the roles of different health professionals in holistic care. Adequately discusses the modes of action, clinical benefits and side-effect profiles of current licensed treatments for MS that are used in Australia. Focus Capability: Self-Directed Learning and Critical Evaluation Adequately reviews the putative roles of viral and environmental factors in MS. Critically evaluates the potential merits and flaws of each of the most commonly held theories (vitamin D, viruses, ethnic and genetic factors). The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide.

References:
Current opinion in Neurology (2011) Volume 24 - Issue 3 (whole issue). Smolders, J., Damoiseaux, J., Menheere, P., Hupperts, R. (2008) Vitamin D as an immune modulator in multiple sclerosis, a review J Neuroimmunol.194(1-2):7-17. Thacker, E.L, Mirzaei, F. and Ascherio, A. (2006) Infectious mononucleosis and risk for multiple sclerosis: a meta-analysis. Ann Neurol. 59(3):499-503. Smestad, C., Sandvik, L., Holmoy, T., Harbo, H.F. and Celius, E.G. (2008) Marked differences in prevalence of multiple sclerosis between ethnic groups in Oslo, Norway. J Neurol. 255(1):49-55. .

Contact:
A discussion regarding this project is available through Blackboard Discussions.

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 87

Project 6: Interview with Health Professionals Working in Palliative Care


Note: this project has a quota of 10 groups. Please register your interest in this assignment through the process described in the introduction to assessment above for projects with quotas. Each group should have 4-6 students.

Graduate Capabilities assessed in this project:


Teamwork Development as a Reflective Practitioner

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
The aims of this Project are for students to gain an insight into the world of health professionals who work in Palliative Care, their personal and professional motivations, their professional challenges and the way their work influences them as individuals.

Course themes and related learning activities:


Palliative Care Multi-disciplinary teamwork

Task description and time allocation guide:


You will be assigned into groups of 4-6. There will be a maximum of 10 groups for this Group Project. Each group will be assigned 2 health professionals working in Palliative Care: 1. A palliative care physician, and 2. An allied health professional e.g. palliative care nurse (hospice); palliative care nurse (community palliative care service); physiotherapist; social worker; pastoral care officer; co-ordinator of hospice volunteers. Each individual health professional can be interviewed by one group only. You will interview the 2 assigned health professionals. Please note: All information shared with you is strictly confidential & must not be discussed outside the group. When writing up the report, you must ensure all references to the place the person works, and their names, are not used. Pseudonyms are acceptable. Your interview may be wide-ranging and creative. Suggested questions may include: Why did you enter your profession? Why did you enter the area of Palliative Care? What are the best aspects of your work? What are the worst aspects of your work? Describe the nature of your work in detail. What advice would you give to medical students about this area? Does it ever become depressing? How do you deal with difficult patients or their relatives? Do you go to the funerals of your patients? You will summarise the main points you have learnt from the interviews with the two health professionals. You will be expected to include a reflection consistent with the capability of Development as a Reflective Practitioner. This may include a critical incident analysis, identification of problems encountered and how they

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 88

could be overcome next time, comparison of this experience with an earlier experience, reflection on feedback on an oral presentation. As a guide for time allocation: Week 1: Organise your interviews. Contact interviewees and organize a time to meet them. Prepare questions and approach. Weeks 2 and 3: Conduct the interviews. Weeks 4 to 6: Write up the interviews and prepare final submission.

Report requirements:
The required length of the Group Project is 2,000 to 2,500 words. Reports should be submitted in 12 point Times New Roman font, double or at least one and a half spaced. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Teamwork Describes the role and responsibilities of health professionals working in Palliative Care. Discuss how they participated as a group. Analyze how well the group worked together on the Project, what styles contributed, what aspects of the group work that was found unhelpful. Evidence of thoroughness of interviewing the health practitioners. Focus Capability: Development as a Reflective Practitioner Critically evaluates communication/interviewing skills employed. Adequately discusses any difficulties in the interviewing process. Openly discusses personal feelings and reactions to the individuals encountered and the content of what they said. Honestly evaluates whether this project has altered personal views about Palliative Care. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide.

References:
Clark, D. (2007) From margins to centre: a review of the history of palliative care in cancer. Lancet Oncology 2007:8:430-438. Kearney, M. (1992) Palliative Medicine just another specialty? Palliative Medicine 1992; 6: 39-46. Barbato, M. (2005) Care of the Dying Patient. Internal Medicine Journal. 35: 636-637. Search on: Palliative Care on Google. For Journals relating to Palliative Care visit: http://www.hospicecare.com/journals_publications.htm

Contacts: Dr JanMaree Davis, Palliative Care Consultant, St George Hospital, Kogarah. Email: janmaree.davis@sesiahs.health.nsw.gov.au

Ageing & Endings A Student Guide Session 2: TP4 2011 Page 89

Project 7: Interview with Palliative Care Patients: Metastatic Malignancy Compared with End Stage Renal Failure
Note: this project has a quota of 5 groups. Please register your interest in this project through the process described in the introduction to assessment above for projects with quotas. Each group should have 4 to 6 students

Graduate capabilities assessed in this project


Teamwork Development as a Reflective Practitioner

The report will also be assessed for each of the generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork).

Aims:
The aims of this Project are for students to gain an insight into similarities and differences in two distinct groups of patients with life-limiting illnesses patients with metastatic malignancy and patients with End Stage Chronic Kidney Disease. In particular, you will compare and contrast the perspectives on their illness and the Palliative Care needs of these groups of patients.

Course themes and related learning activities:


Palliative care Chronic illness

Task description and time allocation guide:


This project is suitable for groups of 4-6 students. There will be a maximum of 5 groups for this Project. Each group will be assigned: 1. A patient with metastatic malignancy. 2. A patient with End Stage Chronic Kidney Disease on dialysis. You will interview the 2 assigned patients. Your interview may be wide-ranging and creative. Suggested questions may include: When were you first diagnosed with this illness? What symptoms were you feeling at the time of diagnosis? How did you feel emotionally when you were first diagnosed? What symptoms are you experiencing now? These may include fatigue, pain, nausea, anorexia in both groups. Note that are specific symptoms of renal disease including itch and restless legs at night. Do you feel that you are easily able to talk to your treating doctor about these symptoms? If not, why not? Is it: a) that you do not want to bother the doctor; b) the doctor seems too busy and when you see him/her there is no time; c) you expect these symptoms with your illness and believe that nothing really can be done? Do you ever get depressed? What are your greatest needs? Do you think they are being addressed adequately? How is your family coping? For the dialysis patients what is it like being on dialysis repeatedly? Is getting in three times a week to have dialysis difficult for you? Do you ever feel like giving up on dialysis? Have you sat with your kidney specialist to draw up an Advanced Care Plan? You will summarise the main points you have derived from the interviews with the two patients. You will be expected to include a reflection consistent with the capability of Development as a Reflective Practitioner. This may include a critical incident analysis, identification of problems encountered with the Project and how they could be overcome next time, comparison of this experience with an earlier experience, reflection on feedback on an oral presentation. Ageing & Endings A Student Guide Session 2: TP4 2011 Page 90

As a guide for time allocation:


Week 1: Weeks 2 and 3: Weeks 4-6: Organise your interviews. Contact interviewees and organise a time to meet them. Prepare questions and approach. Conduct the interviews. Write up the interviews and present final submission.

Report requirements:
A written report, maximum 2,500 words. Reports should be submitted in 12 point Times New Roman font, double or at least one and a half spaced. You should format your report in accordance with the specification on the Medicine program website, and include a word count on the title page (refer to word count guidelines given on page 61). Ensure that you carefully reference your work. Please refer to the Medicine program website for penalties that will be applied to reports that exceed the maximum length: http://medprogram.med.unsw.edu.au/Med3802Web.nsf/page/Assignments%20Projects%20%20P1?open&login#indigroup (login required)

Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria: Focus Capability: Teamwork Adequately describes, compares and contrasts the perspectives and palliative care needs of patients with metastatic malignancy and End Stage Chronic Kidney Disease on dialysis. Clearly describes how the students working on this project performed as a team. Analyse how well the group worked together on the Project, what styles contributed, what aspects of the group work were found to be unhelpful. Focus Capability: Development as a Reflective Practitioner Critically evaluates communication/interviewing skills employed. Adequately discusses any difficulties in the interviewing process. Openly discusses personal feelings and reactions to the individuals encountered and the content of what they said. Honestly evaluates whether this project has altered personal views about Palliative Care. The generic capabilities (Effective communication, Self-directed learning and critical evaluation and Teamwork) will be assessed using the generic criteria listed in the Program guide. Starting references: Barbato, M. (2005) Care of the dying patient. Internal Medicine Journal 35: 636-637. Germain, M.J. (2009) Renal supportive care: why now? Progress in Palliative Care 2009; 17(4): 163-164. (Guest Editorial). Cohen, A.M., Moss, A.H., Weisbord, S.D., Germain, M.J. (2006) Renal Palliative Care. Journal of Palliative Medicine 2006; 9(4): 977-992. Academic contact: Dr Frank Brennan. Email: fpbrennan@ozemail.com.au

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