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Co-Director, Saint Louis University School of Medicine

Standard Treatment Guidelines and Essential Medicines List for South Africa, hospital level, Paeditrics. This book is intended as a starting point in your preparation for getting past the first hurdle, Step 1. Please remember, however, that no single approach to studying is right for everyone. For example, each state board determines the maximum number of times that a person may take each Step exam and still remain eligible for licensure. Step 1 assesses whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine. Mastery of clinical and communication skills, as well as cognitive skills, by individuals seeking medical licensure is important to the protection of the public. The clinical skills examination began in June 2004 and is a separately administered component of Step 2. Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care. Students who delay taking Step 1 until after the start of Year 3 orientation cannot begin the Year 3 clerkships until after the first clerkship or at the midpoint of Year 3. Students who pass on their second attempt can rejoin the Year 3 curriculum at its midpoint. Students who fail their second attempt will continue to be assigned to Independent Study. Students must complete their third attempt to pass Step 1 between March 1st and March 31st. Failure to pass, after the third attempt will result in automatic dismissal from the School of Medicine. At the discretion of the Associate Dean for Student Affairs and the Senior Associate Dean for Education and Academic Affairs, such students will be allowed to walk with their class at commencement and will receive a diploma with a later date, if it is anticipated that they will have met all graduation requirements within a reasonable time after commencement. Passing scores must be documented no later than April 15th of the year the student expects to graduate. Failure to document a passing score for either Step 2 exam by April 15th will result in a delay in graduation. The number of residency positions during this same time period, however, has remained relatively constant thus making it more and more difficult for medical students to be successful in their residency matches. For better or worse, residency programs place a great deal of importance on Step 1 scores when assessing applicants. Step 1 has therefore become the one objective measure common to all residency program applicants that program directors feel they can rely on to help them compare and assess applicants. A very good performance on Step 1 can definitely help when it comes to securing a top-rate residency, and a poor score can hurt by limiting your options. A failure on Step 1 can likewise all but eliminate the possibility of some residencies altogether. Bottom line - although Step 1 is only one of many criteria that will be used in evaluating your residency application, it is definitely in your best interest to do all you can to maximize your chances of doing well, regardless of what type of specialty training you may choose to pursue. The number of test items you answer correctly is converted to a three-digit score scale. The mean score for first-time examinees from accredited medical school programs in the United States is in the range of 215 to 235 with a standard deviation of approximately 20. Your score report will include the mean and standard deviation for recent administrations of the Step exam. Blocks of items on Step 1 are constructed to meet specific content specifications. As a result, the combination of blocks of items on any given Step 1 exam creates a form that is comparable in content to all other forms.

Foster-Kennedy syndrome (tumour near one optic foramen leading to optic atrophy on that side and papilloedema on the other side). Pseudotumour cerebri: this is usually an idiopathic condition, especially affecting young and obese women, who present with features of raised intracranial tension (headache, papilloedema and sixth nerve palsy). Dirty white appearance of optic disc due to reactive gliosis (secondary optic atrophy). Nervous System Pseudo-papilloedema In this condition, there is a filling up of the optic disc, but there is absence of venous congestion or swollen and proliferated capillaries around the disc margin. It is due to congenital disc anomalies giving rise to apparent rather than true disc swelling. Small/absent optic cups, abnormal branching of the major retinal vessels and calcific excrescences may be seen. Hypermetropia (due to increased myelin deposition anterior to the lamina cribrosa). Transient loss of vision, while straining or bending forward in the presence of papilloedema is due to compression of the central retinal artery and is an indication for urgent removal of the underlying cause of papilloedema. Primary (simple) optic atrophy Primary optic atrophy is characterised by orderly degeneration of optic fibres and is replaced by columns of glial tissue without any alteration in the architecture of the optic nerve head. The entire architecture of optic nerve head is lost resulting in indistinct disc margins. Secondary optic atrophy Secondary optic atrophy is characterised by marked degeneration of optic nerve fibres with excessive. Consecutive Chorioretinitis Pigmentary retinal dystrophy Cerebromacular degeneration Extensive photocoagulation Toxic (quinine) retinopathy Myopic chorioretinal degeneration. Post-inflammatory Optic neuritis Perineuritis (post-meningitis, orbital cellulitis). Metabolic Thyroid ophthalmopathy Cystic fibrosis It is the edema of the optic disc < 3 dioptres. Patient experiences pain in the eye on moving the affected eyeball and there is a sudden loss of visual acuity. Painful condition Central scotoma Sudden loss of vision can occur Swelling of disc < 3 dioptres Due to demyelination Steroids (prednisolone 60 mg per day given early may shorten course of illness) Papilloedema Painless Peripheral constriction of visual field No visual loss Swelling of disc > 3 dioptres Causes listed above Treatment of the underlying cause 455 2. Amaurosis fugax: It is a transient monocular blindness, lasting for a few seconds and occasionally for a few hours. Microembolism of central retinal artery with platelet or cholesterol emboli from ipsilateral carotid artery 3. Examination of the Macula the abnormalities of the macula that may be noticed are 1. The unpaired column constitute Edinger-Westphal nucleus and subnucleus for levator palpebrae superioris. The paired nuclei constitutes subnuclei for superior, inferior and medial recti and inferior oblique. Trochlear nerve passes posteriorly and the fibres from the right and left trochlear nuclei decussate on the dorsum of mid brain. The left trochlear nucleus sends fibres to the right superior oblique muscle, and vice versa. Abducent nerve has a very long intracranial course and supplies the lateral rectus muscle. Because of its long intracranial course, it is affected in conditions producing raised intracranial tension, thereby producing a false localising sign. The clinical signs include abnormal upper eyelid movement (lid elevation) on attempted ipsilateral adduction/depression of the eye. Ptosis may be congenital or acquired, unilateral or bilateral, partial or complete. Congenital ptosis: It is due to bilateral congenital hypoplasia of the third nerve nuclei, and results in bilateral ptosis.

Young children with type 1 diabetes and the elderly, including those with type 1 and type 2 diabetes (77,82), are noted as particularly vulnerable to clinically significant hypoglycemia because of their reduced ability to recognize hypoglycemic symptoms and effectively communicate their needs. For patients with type 1 diabetes with severe hypoglycemia and hypoglycemia unawareness that persists despite medical treatment, human islet transplantation may be an option, but the approach remains experimental (83,84). An additional goal of raising the lower range of the glycemic target was to limit overtreatment and provide a safety margin in patients titrating glucose-lowering drugs such as insulin to glycemic targets. Hypoglycemia Treatment with hypoglycemia-prone diabetes (family members, roommates, school personnel, child care providers, correctional institution staff, or coworkers) should be instructed on the use of glucagon kits including where the kit is and when and how to administer glucagon. An individual does not need to be a health care professional to safely administer glucagon. Hypoglycemia Prevention Providers should continue to counsel patients to treat hypoglycemia with fastacting carbohydrates at the hypoglycemia alert value of 70 mg/dL (3. Hypoglycemia treatment requires ingestion of glucose- or carbohydratecontaining foods. The acute glycemic response correlates better with the glucose content of food than with the carbohydrate content of food. Pure glucose is the preferred treatment, but any form of carbohydrate that contains glucose will raise blood glucose. In type 2 diabetes, ingested protein may increase insulin response without increasing plasma glucose concentrations (85). Ongoing insulin activity or insulin secretagogues may lead to recurrent hypoglycemia unless further food is ingested after recovery. Patients should understand situations that increase their risk of hypoglycemia, such as fasting for tests or procedures, delayed meals, during or after intense exercise, and during sleep. Hypoglycemia may increase the risk of harm to self or others, such as with driving. Teaching people with diabetes to balance insulin use and carbohydrate intake and exercise are necessary, but these strategies are not always sufficient for prevention. In type 1 diabetes and severely insulindeficient type 2 diabetes, hypoglycemia unawareness (or hypoglycemia-associated autonomic failure) can severely compromise stringent diabetes control and quality of life. This syndrome is characterized by deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response, which both are risk factors for, and caused by, hypoglycemia. A corollary to this "vicious cycle" is that several weeks of avoidance of hypoglycemia has been demonstrated to improve counterregulation and hypoglycemia awareness in many patients (86). Hence, patients with one or more episodes of clinically significant hypoglycemia may benefit from at least short-term relaxation of glycemic targets. If accompanied by ketosis, vomiting, or alteration in the level of consciousness, marked hyperglycemia requires temporary adjustment of the treatment regimen and immediate interaction with the diabetes care team. The patient treated with noninsulin therapies or medical nutrition therapy alone may temporarily require insulin. A physician with expertise in diabetes management should treat the hospitalized patient. Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D Exchange clinic registry participants. Dual use of Department of Veterans Affairs and Medicare benefits and use of test strips in veterans with type 2 diabetes mellitus. A randomised, 52-week, the use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth. Those in close contact with, or having custodial care of, people For further information on management of patients with hyperglycemia in the hospital, please refer to Section 14 "Diabetes Care in the Hospital. Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose; ketosis- care. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. Simon J, Gray A, Clarke P, Wade A, Neil A, Farmer A; Diabetes Glycaemic Education and Monitoring Trial Group. Glucose self-monitoring in noninsulin-treated patients with type 2 diabetes in primary care settings: a randomized trial. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Glycaemic impact of patient-led use of sensorguided pump therapy in type 1 diabetes: a randomised controlled trial.

The terms "peer" and "recovery coach" are used purposely to reflect a mutual, peer-based collaboration to help people achieve sustained recovery. Peer recovery coaches do not espouse any specific recovery pathway or orientation but rather facilitate all pathways to recovery. This stems from the newness of this practice and the diversity of the populations that recovery coaches serve. As use of this type of support expands, some national norms of practice and behavior will likely form over time, but with significant flexibility to enable sensitivity to local realities. Therefore, residence in the sober living home cannot be assumed to have caused the better outcomes observed. Taken together, these studies provide promising evidence to suggest that recovery-supportive housing can be both cost-effective and effective in supporting recovery. Each Oxford House is a self-supporting and democratically-run substance-free residence. Ensure that houses are self-governed and run according to Oxford House standards and guidelines. In a comparison study between Oxford House residents and a group that was assigned usual aftercare services, the Oxford House group had significantly lower substance use (31. With the core components of tracking, assessment, linkage, engagement, and retention, patients are monitored quarterly for several years following an initial treatment. If a relapse occurs, the patient is connected with the necessary services and encouraged to remain in treatment. The main assumption is that early detection and treatment of relapse will improve long-term outcomes. It can be provided by professionals or by peers, although only the former approach has been rigorously studied. One example is an extended case monitoring intervention, which consisted of phone calls on a tapering schedule over the course of several years, with contact becoming more frequent when needed, such as when risk of relapse was high. This intervention was designed to optimize the cost-effectiveness of alcohol treatment through long-term engagement with clients beyond the relatively short treatment episodes. Case monitoring also reduced the costs of subsequent outpatient treatment by $240 per person at 1-year follow-up, relative to patients who did not receive the telephone monitoring. Telephone monitoring produced the highest rates of abstinence from alcohol at followup 12 months later. Many recovery community centers are typically operated by recovery community organizations. Recovery community centers are different from professionally-operated substance use disorder treatment programs because they offer support beyond the clinical setting. Recovery-based Education High school and college environments can be difficult for students in recovery because of perceived and actual high levels of substance use among other students, peer pressure to engage in substance use, and widespread availability of alcohol and drugs. Such schools support abstinence and student efforts to overcome personal issues that may compromise academic performance or threaten continued recovery. Rates of abstinence from "all alcohol and other drugs" increased from 20 percent during the 90 days before enrolling to 56 percent since enrolling. A rigorous outcomes study is nearing completion that will give a better idea of the impact of recovery high schools. Most provide some combination of recovery residence halls or recovery-specific wings, counseling services, on-site mutual aid group meetings, and other educational and social supports. These services are provided within an environment that facilitates social role modeling of sobriety and connection among recovering peers. The programs often require participants to demonstrate 3 to 6 months with no use of alcohol and drugs as a requirement for admission.