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They may often seem overly conser- vative discount 20 desogen mastercard, but this can be attributed to the physician’s painfully acquired distrust of panaceas buy desogen 20 with visa. There is a generally accepted need to preserve certain fundamental principles—the axiom discount desogen 20 mastercard, for example, that the rational practice of medicine rests on a frm understanding of the basic medical sciences. Yet the great advances in medicine, the need to reasonably limit the number of years of formal education, the increasing number and complexity of special felds, and the diversity of interests and talents among students all demand continual examination of our educational aims and process. Old traditions and new methods are characteristics of the Johns Hopkins University School of Medicine, which to a large degree was founded in response to the highly variable standards of medical educa- tion at the time. Hopkins was the frst medical school in the United States to require a college degree for admission, quite a radical idea when the frst class entered over one hundred years ago. A college degree is still required, and current admission policies encourage a broad undergrad- uate education and permit successful applicants to select from a num- ber of options prior to matriculation. The relative fexibility of the original curriculum foreshadowed the even greater number of choices available today. The wide variety of elective courses in the current curriculum allows students to extend their knowledge in special felds of interest and to schedule elective and required clinical courses in a fexible manner. Also, selected students are given the opportunity to work simultaneously towards both the M. The University was incorporated in 1867 nately, what was ample in 1867 was no longer under the terms of his bequest, and instruc- so twenty years later. Garrett was the principal sity of California, was elected frst president of donor. In his inaugural address cational foundation of the School of Medicine in 1876, Gilman elaborated his philosophy of soon after his investiture. He was duly con- education, in terms both prophetic and prac- cerned with the lack of fundamental knowl- tical, which was to become the guiding prin- edge of biology, chemistry, physics, and ciple of the University. Students should be modern languages in students undertaking free to select under guidance their courses the study of medicine. He therefore organized of study; professors should be free of routine; a “preliminary medical course” in the Fac- investigators should be “free, competent, and ulty of Philosophy, setting a standard which willing” research and teaching should supple- ultimately became a prerequisite for admis- ment one another. This was a great so much to impart knowledge to the pupils, departure from the then accepted require- as to whet the appetite, exhibit methods, ments for admission (see Appendix). Newell Martin, During President Gilman’s twenty-fve years Ira Remsen, John Shaw Billings, and William of enlightened leadership, his high hopes H. It was in this environment Welch began to organize courses in pathol- of the frst true university in America that the ogy and bacteriology for practicing physi- School of Medicine was evolved. Thus, the prin- seventeen years after the University’s found- ciples of postgraduate medical education and ing. Part of this delay was occasioned by the research were established even before the desire to have a fully equipped hospital before School was offcially in existence. The Johns Hopkins In 1888 William Osler was called from the Hospital was completed in 1889, and from the University of Pennsylvania to be Physician- outset its destiny has been inextricably woven In-Chief to the Hospital and Professor of the with that of the School of Medicine. This policy Theory and Practice of Medicine in the Univer- was established in a letter from Mr. Kelly were summoned to the chairs arrangements in relation to this hospital,” he of Surgery and Gynecology and Obstetrics, wrote, “you will bear constantly in mind that respectively. Also called from many parts of 7 the country to serve on the faculty when the clinics a new approach to surgery based on school opened in 1893 were Henry M. He also, with Superintendent of the Johns Hopkins Hospi- Welch, championed the system of full-time tal and subsequently Professor of Psychiatry, clinical departments. Mall, Professor of Anatomy, John Board’s establishment, in 1913, of The William J. Welch served as Professor of Pathol- sible instructors in Medicine, Surgery, Pediat- ogy and Dean of the Medical Faculty. The endowments of sity School of Medicine marked a new depar- the Henry Phipps Psychiatric Clinic and the ture in medical education in America because William Holland Wilmer Ophthalmological it was the frst time that all professors in the Institute accomplished the same ends for the preclinical branches served on a full-time Departments of Psychiatry and Ophthalmol- or university basis. Each of the clinical departments of the Physiology, Pharmacology, and Pathology School is now staffed by men and women who in the School were from the outset true uni- devote their entire time to teaching, hospital versity chairs, flled by men who gave their practice, and research, as well as by practic- “entire time and strength’’ to the University, to ing physicians who perform these duties on a use Gilman’s words. Of all over the country would follow the lead, and comparable signifcance, perhaps, was the medical education, instead of being largely development of the graduate school concept a proprietary business conducted for proft, in medical education. Students in their clinical would become a major concern of university years at the Johns Hopkins School of Medi- endeavor. They were also encouraged to the development in America of exact diagno- participate in research activities in the labo- sis, with the assistance of the laboratory, and ratories and clinics under the supervision of detailed description of disease. Graduates of the the foundations for intern and residency train- School introduced the Hopkins practices ing in American hospitals. Halsted and his elsewhere when called to fll posts at other colleagues developed in the laboratories and institutions. As a measure of their competence, every Professionalism graduate of the Johns Hopkins University • Display the personal attributes of com- School of Medicine will: passion, honesty and integrity in relation- The Science and Practice of Medicine ship with patients, families, and the medical community. Johns Hopkins Medicine The Johns Hopkins Hospital are often referred and School of Medicine administrative offces to as the Johns Hopkins Medical Institutions. The preclinical cur- Instruction in the School of Medicine is riculum for medical students is taught in the under the supervision of the Advisory Board new Anne and Michael Armstrong Building, a of the Medical Faculty, composed of the four story, 100,000 square foot structure which President of the University, the Dean and the opened in the Fall of 2009. Today, it is the largest school of public cal Chemistry, Biophysics and Biophysical health and provides opportunities for graduate Chemistry, Cell Biology, Functional Anat- education to individuals from a wide variety of omy and Evolution, Molecular Biology and backgrounds and experience. Programs of study embrace Basic Science, Preclinical Teaching Building, research and service in diverse felds: profes- Biophysics, Physiology, and the Broadway sional practice, basic and applied research; Research buildings. The Wood Basic Sci- social policy; planning, management and ence Building and the Preclinical Teaching evaluation of the delivery of health services; Building contain teaching laboratories, con- and the biological and environmental health ference rooms, and lecture halls for gradu- sciences. Graduate training programs in clini- ate student teaching, as well as research cal investigation, pre- and postdoctoral train- laboratories.

Lenzenweger ea (2004) also found considerable variability in features of personality disorder over time cheap desogen 20 without prescription. Some forensic issues ‘It seems clear …that it is impossible at present to decide whether personality disorders are mental disorders or not discount desogen 20 mastercard, and that this will remain so until there is an agreed definition of mental disorder’ purchase 20 desogen amex. The commonest diagnoses among convicted murderers in this part of the world are personality disorder, alcohol misuse, and drug abuse. However, without assertive follow up, mentally ill ex-prisoners are prone to lose contact with services, to re-offend and up back in custody. Children of criminals or psychopaths adopted by ‘normals’ are more likely to show antisocial behaviour than the offspring of ‘normals’. Most such children are quickly recovered since there may be no attempt to conceal them. Personality disorder (ill defined with overlap of categories) or psychosis (usually schizophrenia) are common in perpetrators. The act may satisfy an emotional need, may be used to manipulate the environment, or may be impulsive and psychotic. In one study the great majority of those who assaulted their wives had a personality disorder. Objections included 1864 unfairness to the female sex (who may be victimised in relationships and end up with a label ) and possible confusion with depression. It has been suggested that people with masochistic personality disorder become hypochondriacal manipulators when they cannot obtain love and nurturance by other routes: an abusive attachment is better than no attachment. His thinking from viewing masochism as part of a spectrum shared with sadism to one of Thanatos (the masochist wished for self-destruction). In contrast to Freud, Horney, in the 1940s, believed that sadism wasn’t necessarily sexual in origin - that is that personality- based attitudes were bound to manifest themselves at some stage through sexual activity. The aim should be change real life behaviour rather than simply look for change in the treatment setting. Although rotation systems make it difficult, as far as possible the one therapist should continue to see the patient. Millon and Davis (2000) consider the psychotherapies just as good and just as bad as one another when applied to the personality disorders. Efficacy should be subject to ongoing scrutiny and spurious ‘cures’ should be studied critically. Development of a therapeutic alliance and acknowledgement of vulnerability to manipulation by therapists are important ingredients of any therapeutic approach. The evidence-base for many drug-based ‘treatments’ for personality disorder is flimsy. The Dangerous People with Severe Personality Disorder Bill was introduced in 2000 by the British Labour government with the aim of removing people who might commit future crimes from society. Certain prisons and special hospitals are assigned the role of detaining such individuals. There is a feeling of pleasure, gratification, or release at the time of the act, and the act is consonant with the immediate conscious wish of the person, i. Following the act there may or may not be feelings of regret, self-reproach, or guilt. Nidotherapy (changing the person’s environment rather than trying to change the person) and transference-focused therapy (dysfunctional relationships are examined within the transference and the patient is taught to reflect) are some other approaches. Comorbidity with anxiety, mood, eating, substance, other impulse control, and personality disorders (especially borderline and antisocial) is common. It is associated with illegal money making, scams aimed at extracting money from others, and disorders involving poor impulse control such as antisocial personality disorder, drug abuse, pathological gambling, and bipolar disorder. Pyromaniacs are fascinated by fire, are fire-watchers, and, despite often not caring about the consequences of fires, may volunteer to help put out fires. Insight is poor, alcoholism is common, and patients often will not accept responsibility for their actions. Women may start gambling later than men, but there seems to be no significant difference between the sexes in terms of the age at presentation for treatment. It is abnormal if the gambler or his family view it as excessive; it is the sole relief from tension; the practitioner is preoccupied with it; there is loss of control over the amount gambled; and, if any important sphere of life (in gambler or dependants) is adversely affected. Pathological gambling might start when a (perhaps psychologically vulnerable) person observes others gambling and be maintained by variable ratio reinforcement scheduling. Addictive or impulsive behaviour in general may involve increased dopamine and noradrenaline activity 1869 and a reduction in serotonin. The relaxed patient imagines a hierarchy of situations leading to gambling and then imagines leaving the scene without gambling. Controlled gambling is sometimes offered as an alternative strategy to abstinence, although, as with alcoholism, it is by no means certain how to predict who is likely to benefit. There are many methodological problems to be considered in evaluating such research, particularly the small numbers involved. Noradrenaline is important in being prepared for stimulation whereas dopamine is concerned with reward and reinforcement. They should not have credit cards and it may be better if a responsible other handles their finances. It appears most likely that eating disorders are triggered by socio-cultural and interpersonal stressors and may then be sustained by neural networks including those subserving homeostasis (brain stem/hypothalamus), drive (mesolimbic cortex/striatum), and self regulation (top-down control that views appetite in terms of the wider context of goals, values, and meaning). Overlap syndromes and subtype changes over time in individual patients are common. Many cases of anorexia nervosa graduate to bulimia nervosa, whereas movement in the opposite direction is less common. Eating disorders (threshold and below) are not uncommon in adolescent females who have type I diabetes mellitus, and these patients are prone to omitting insulin in the hope of losing weight.

In recent years there has text of the healthcare setting or clinical problem and is dependent been a steady development of multicentre prehospital care research on the needs and scope of the wider health system buy cheap desogen 20 on-line. For example cheap desogen 20 otc, that utilizes robust methods in order to answer some of the more alternatives to ambulance transportation to emergency depart- challenging questions about interventions in prehospital care buy desogen 20 online. In addition, ambulance services have always per- or trauma whereas there is little evidence on assessment for many ceived themselves as having research ‘done on’ them by outsiders other acute or chronic conditions. This Although progress is being made in some areas such as devel- has largely been due to a lack of research capacity and exper- opment of performance measures for ambulance services, this is tise in ambulance services. For example, patient outcome- due to increased numbers of paramedics gaining an undergrad- based measures will require better information sourced from uate degree and postgraduate qualifications also being achieved. Improved funding and stronger collaborations between prehospital As in other areas of practice, implementation of research and care and academic institutions is also making prehospital research knowledge translation is slow. Research priorities Barriers and facilitators Research priorities identified through in the literature can be found in Box 38. Historically there have been a number of barriers to undertaking research in emergency settings (Box 38. As in many areas of health care, there are tensions between delivering services and undertaking research. The ambulance service is no longer Conflicting priorities seen as a ‘scoop and run’ service and has expanded its scope of Lack of interest care to include the assessment and treatment of patients on scene Inadequate capacity and capability with appropriate signposting to services where required. Numer- Poor organization ous studies have shown that this can be effective, for example Limited funding. The context of diverse or rapidly changing health systems or Systems organization of care is another barrier, particularly when studies Prehospital care should not be considered in isolation. Although patient outcomes are dependent pered by local and regional differences in pathways, the numbers of on the whole system rather that the component parts, the process organizations involved and changes in systems and processes of care of care within the prehospital setting is an important contributor due to national guidance. The ability to evaluate process and outcomes methods employed – for example a randomized controlled trial in the emergency care system is challenging, but appealing. System evaluating a service or pathway may be impossible if that service is performance, quality and safety of care are key drivers for change, already fully established. Normally where capacity for consent the impact on patients and services of bypassing local emergency is not present the legislation allows for personal or professional departments in favour of specialized centres such as trauma centres legal representatives to give consent on behalf of the patient. While policy is driving emergency situations where capacity is present but the patient has the changes, the evidence supporting it is lacking and research is little time for fully informed consent as a result of their condition needed to address these deficiencies. Drugs and devices Specific methods such as cluster randomization, where random- The use of new technologies within prehospital care should ideally ization of groups of patients treated by one or more ambulance be evaluated within that setting. It is no longer sufficient to translate clinicians rather than randomization of individual patients may findings from other clinical settings and assume the effects will be reduce some of the requirements for individual patient consent in similar. However, in many such studies individual consent proves one of the most challenging for researchers and therefore is still required for individual level data such as quality of life or drug or device trials are rarely undertaken in these settings. Pre- data requiring review of subsequent clinical and service utilization viously successful trials demonstrated the benefit of interventions records. The knowledge and expertise needed to consent patients such as prehospital thrombolysis, and more research of this quality by front line staff is often lacking, particularly in ambulance services should be undertaken. Such training requires resources Future directions and considerable effort but should be considered as an investment in future capacity for research. Therearecontinuingchallengesforprehospitalcareresearchworld- New systems for ethical review and approval of research studies wide. The setting and often urgent nature of the clinical conditions have been developed to enable more efficient processes but many presented make research in this area challenging. However, this ethical and other complexities of prehospital research are prob- should not act as a deterrent, but be utilized to develop strong and lematic for research ethics committees and health organizations effective collaborations that can deliver a sound research evidence responsible for research governance. The future of prehospital care should focus on developing a diverse service that takes healthcare to the patient and directs ongo- New technologies ing care from that point. This means that healthcare professionals Evaluating the clinical and cost effectiveness of new technologies in will need to have a range of skills, equipment and pathways open order to inform their integration into healthcare is essential. In the to them in order to deliver the most appropriate and cost-effective past, the evidence for what we do has been scanty. A mobile intensive care unit in the management of • Recent evidence reviews have highlighted priorities for future myocardial infarction. Supporting research • The context of prehospital medicine makes research challenging; and development in ambulance services: research for better health care in especially clinical trials where interventions can have a significant prehospital settings. Prehospitalthrombolytic Tips from the field therapy in patients with suspected acute myocardial infarction. London: Department and data collection may seem arduous but it will lead to of Health, 2010. S p e c i a l I m a g i n g S t u d i e s E m e r g e n c i e s f o r t h e E m e r g e n c y D e p a r t m e n t : A n g i o g r a p h y M R I V / Q 1 0. I n f e c t i o u s D i s e a s e E m e r g e n c i e s T h e V a d e m e c u m s e r ie s in c l u d e s s u b j e c t s g e n e r a l l y n o t c o v e r e d in o t h e r h a n d b o o k s e r i e s , e s p e c i a l l y m a n y t e c h n o l o g y - d r i v e n t o p i c s t h a t r e f l e c t t h e i n c r e a s i n g Digitally signed by in f l u e n c e o f t e c h n o l o g y in c l in ic a l m e d ic in e. T h e n a m e c h o s e n f o r t h is c o m p r e h e n s iv e m e d ic a l h a n d b o o k s e r ie s is V a d e m e c u m , malina a L a t in w o r d t h a t r o u g h l y m e a n s “ t o c a r r y a l o n g ”. I n t h e M id d l e A g e s , t r a v e l in g c l e r ic s c a r r ie d p o c k e t - s iz e d b o o k s , e x c e r p t s o f t h e c a r e f u l l y t r a n s c r ib e d c a n o n s , k n o w n a s V a d e m e c u m. T h e L a n d e s B io s c ie n c e V a d e m e c u m b o o k s a r e in t e n d e d t o b e u s e d b o t h in t h e Date: 2006. S p e c i a l I m a g i n g S t u d i e s E m e r g e n c i e s f o r t h e E m e r g e n c y D e p a r t m e n t : A n g i o g r a p h y M R I V / Q 1 0.