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Albumin microspheres cytotec 100mcg on-line, although less available buy discount cytotec online, give a more homogeneous particle size buy 100 mcg cytotec mastercard. The minimum number of particles necessary to obtain an even distribution of radioactivity in the vascular bed is 60 000; hence it is reasonable to use about 100 000 particles generic 100 mcg cytotec free shipping, which will transiently occlude one in 1500 arterioles of the lung. Since both agents are labelled with 99mTc, it is extremely important for the count rate of the second study to be at least four times that of the first study. The radioactive gases 133Xe or 81mKr are unavailable in many countries so that radioaerosols are preferred. Preparation and procedure (a) Patient preparation A chest radiograph in both the anterior–posterior position and with lateral projections should be obtained before lung scintigraphy for pulmonary embolism. A portable anterior–posterior chest radiograph is acceptable only if the patient cannot tolerate a routine upright examination. In patients who have no changes in signs or symptoms, a chest radiograph within one day of scinti- graphy is adequate. A more recent radiograph (preferably within 1 hour) is necessary in patients with evolving clinical status. Before intravenous administration of the pulmonary perfusion radio- pharmaceutical, the patient should be instructed to cough and to take several deep breaths. The patient should be in a supine position during injection or, in the case of a patient with orthopnea, as close to the supine position as possible, since particle distribution is affected by gravity. For example, half the usual activity may be used for the perfusion study and the ventilation study is omitted if possible. The pertinent clinical history should include details on: —Right-to-left shunt(s); —Severe pulmonary hypertension; —Chest pain; —Dyspnea; —Haemoptysis; —Syncope; —Symptoms of deep venous thrombosis; —Oral contraceptive use; —Recent surgery; —Prior pulmonary embolism(s); —Cancer; —Congestive heart failure; —Underlying or previous diseases; —Smoking; —Intravenous drug abuse; —Long air flights. Other factors may also be relevant; a physical examination includes vital signs, chest cardiac examination and leg findings, among other aspects. Treatment with anticoagulants or thrombolytic therapy should be noted, as should the results of tests for deep venous thrombosis, for example compression ultrasonography. The referring physician’s estimate of the prior probability of pulmonary embolism may be helpful, or may be assessed from a properly completed request form. In adults, the number may be reduced to between 100 000 and 200 000 particles without significantly altering the quality of the images for detection of perfusion defects. Inhomogeneous distribution of activity may result from a reduction in the number of particles to below 100 000 in adults. In aerosol ventilation imaging, the aerosol is administered through a mouthpiece with the nose occluded and the patient performing tidal breathing. An advantage of aerosols is that images can be obtained in multiple projections to match those obtained for perfusion. It is preferable to have the patient inhale the aerosol in the upright position, although the supine position can be used if necessary. The physician should not administer the radiotracer in the distal port of a Swan– Ganz catheter or any indwelling line or port that contains a filter, for example a chemotherapy line. Imaging is preferably performed in the upright position to increase chest cavity size and minimize diaphragmatic motion. Planar images should be obtained in multiple projections including anterior, posterior, both posterior oblique, both anterior oblique and both lateral projections. A minimum of six views, each of ventilation and perfusion, are required for reliable interpretation. Interpre- tation is improved with six perfusion and ventilation images: (1) High probability (>80%, in the absence of conditions known to mimic pulmonary embolism): — At least two large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or large and moderate defects; —Two large mismatched segmental perfusion defects, or the arithmetic equivalent. Although a very long list of differential diagnoses exists for ventilation–perfusion mismatch findings, the most common causes include only a few: —Acute pulmonary embolism; —Old pulmonary embolism (without reperfusion); —Obstruction of a pulmonary vessel by a tumour; —Previous radiation therapy to the thorax. On perfusion scintigraphy, extrapulmonary activity (which may be seen at the edges of lung images in the thyroid or kidneys) may be due to right-to-left 99m shunt, free Tc-pertechnetate or reduced technetium compounds, or a recent nuclear medicine procedure. An image of the head can be used to differentiate free pertechnetate or reduced technetium from a shunt. The stripe sign (activity at the periphery of a perfusion defect) lowers the chance of pulmonary embolism in the zone of the perfusion defect that shows the stripe. Ventilation scintigraphy is obtained at a different point in time than perfusion scintigraphy. Similarly, ventilation scintigraphy may be obtained in an upright position and perfusion scintigraphy injected in the supine position. These changes in position may also affect the comparability of the two scintigrams. Principle Liver–spleen imaging is performed following the injection of a 99mTc labelled colloid, which is rapidly phagocytized by the reticuloendothelial cells of the liver, spleen and bone marrow. Clinical indications (a) Liver–spleen imaging These studies can be used for determining the size and shape of the liver and spleen as well as for detecting functional abnormalities of the reticulo- endothelial cells of these organs. Specifically, these studies are occasionally performed for: (1) Suspected focal nodular hyperplasia of the liver. The decision to perform a liver biopsy or to continue treatment with a hepatotoxic agent may be influenced by the severity of the liver disease that is seen on liver–spleen imaging as a complement to blood tests. The sensitivity for detecting large lesions (more than 2–3 cm) is very high, but hemangiomas as small as 0. They are often performed: —In children, to rule out congenital asplenia or polysplenia; 268 5. Methods with higher labelling efficiency (in vitro and in vivo, or in vitro) may improve the results of imaging. Appropriate procedures and quality assurance for the correct identification of patients and the handling of blood products are imperative. Procedures (a) Image acquisition (1) Liver–spleen imaging Imaging is begun 10–15 min or longer after the intravenous adminis- tration of 99mTc-colloid. Anterior, posterior, right lateral, right anterior oblique and right posterior oblique images of the liver are commonly obtained. Subsequent images are then obtained for the same length of time as for the anterior image. A size marker and a costal margin marker are needed for measuring liver and spleen size and for identifying anatomical landmarks. Such dynamic studies should be performed in the view that is most likely to show the lesion. This view should be selected on the basis of the location of the lesion of interest, which has usually been documented in a previous imaging study (i. Immediate blood pool images should be obtained in the view most likely to show the lesion, as well as in anterior, posterior and right lateral views. Delayed (45–180 min post-injection) blood pool images are obtained in the anterior, posterior and right lateral views for 1 000 000–2 000 000 counts each. A hepatic perfusion index, comparing the hepatic artery and portal counts to total blood flow, may also be obtained from the dynamic flow study and the corresponding hepatic time–activity curve. Anterior, posterior and right lateral images of the liver containing 500 000–1 000 000 counts are typically acquired. If the patient has had prior trauma that may have resulted in a diaphragmatic rupture, the chest should also be imaged. Focal nodular hyperplasia may have activity equal to, or greater than, the surrounding liver in about 50% of patients. Normal activity or increased activity found in a lesion is very specific to focal nodular hyperplasia. Visuali- zation of the caudate lobe only (with splenic enlargement) is typical of the Budd–Chiari syndrome due to hepatic vein thrombosis. A relative radiocolloid ‘shift’ (increased radionuclide deposition in the spleen and bone marrow relative to the liver) may occur in liver cirrhosis but also in any diffuse form of hepatic dysfunction, portal hypertension, hyper- splenism and marrow-active anaemia as a response to chemotherapy, as well as in some patients with malignant melanoma. In patients with diffuse parenchymal disease, serial studies can document the progression and severity of the disease. Hemangiomas typically have reduced or normal initial blood flow with increased activity on delayed images. Cavernous hemangiomas that are 3 cm or greater in size almost always demonstrate a markedly increased blood pool even on planar images. A hepatoma usually shows increased early perfusion followed by a defect, whereas abscesses and cystic lesions are hypoactive in all phases of the study. The presence of extrahepatic subdiaphragmatic activity indicates that the catheter is not optimally positioned. When multiple lesions have been noted in other imaging studies, the presence or absence of an increased blood pool should be reported on a lesion- by-lesion basis when possible.

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Differentiation (Millon & Davis buy generic cytotec 200 mcg online, 2000) Paranoid - believes he is the object of a conspiracy Avoidant - sees himself as ridiculous (but may interpret routine questions as criticism) Schizoid - derives little from interpersonal relationships Avoidants - interpersonal relationships are punishing; prefers advance notice of what others expect 1857 Avoidant cases may have been very submissive when growing up purchase generic cytotec line, or they may have had a longterm physical illness cytotec 200 mcg visa. Therapists may be milked for constant reassurance order cytotec 200mcg on line, especially that he/she will not desert the patient. The therapist must not exploit or encourage submissiveness, or to reject a clingy client. There is a very high comorbidity rate between avoidant personality disorder and social phobia (Pigott & Lac, 2002) leading some authorities to suggest that they are synonymous. Many people are shy right up into adolescence and it may be erroneous to regard them as having avoidant personality disorder. The term ‘narcissism’ was introduced by the English sexologist Henry Havelock Ellis (1859-1939) in 1898. Psychoanalysts then used the term to describe a reaction to damaged self-esteem: ‘narcissistic injury’. These patients are submissive and appeasing in relationships and inhibit negative responses for fear of destroying a relationship. Group therapy may encourage efforts at autonomy by practicing alternative coping styles in a safe setting. Families must be won over so that any changes in the patient are not met with negative responses. One theory is that people with this personality disorder were the victims of excessive rage and humiliation in childhood. However, once interrupted they may view the therapist as unhelpful or unprofessional. Also, the present author is struck by how many ‘house proud’ depressives he has encountered. An essential first step is to develop a (tentative and often brittle) trusting relationship. When psychoanalytic psychotherapy is undertaken it is important for the therapist to take an active stance and to promote a focus on (avoided) feelings and the patient’s need for control rather than engage in endless intellectualisation. It may overlap aetiologically with major depressive disorder but a twin study suggests that it is a distinct entity. F62 is called ‘enduring personality changes, not attributable to brain damage and disease’. There should not have been a previous personality disorder that explains current traits. The change is aetiologically traceable to a profound, existentially extreme experience. Examples include enduring personality change following torture or concentration camp experiences. This phenomenon, known as hardening of the categories, results in overgeneralization and inflexibility". Rosowsky and Gurian (1991) provide the example of prescribed medication misuse replacing earlier self-mutilation in borderlines. Certain factors, like artistic talent, were conducive to a better outcome, while others, such as parental cruelty, were associated with a poorer outlook. Lenzenweger ea (2004) also found considerable variability in features of personality disorder over time. Some forensic issues ‘It seems clear …that it is impossible at present to decide whether personality disorders are mental disorders or not, and that this will remain so until there is an agreed definition of mental disorder’. 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).

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Basics of legal proceedings in Forensic Medicine in the Republic of Bulgaria (Penal Procedure Code and Code of Civil Practice) order online cytotec. Blunt force trauma – definition buy 200mcg cytotec visa, types buy cytotec with mastercard, mechanism of causation order cytotec 100 mcg without prescription, morphological characteristics of the injuries. Abrasions – definition, mechanism of causation, morphological characteristics, medicolegal importance. Bruises – definition, mechanism of causation, morphological characteristics, medicolegal importance. Lacerations - definition, mechanism of causation, morphological characteristics, medicolegal importance. Motor vehicle trauma – definition, classification, major issues concerning Forensic Medical Expert Examinations. Common morphological characteristics in cases of death caused by mechanical asphyxia-postmortem appearances. Airway obstruction, postural asphyxia, asphyxia due to exhaustion or displacement of environmental oxygen. Major issues of Forensic Medical Expert Examination in cases of mechanical asphyxias. Major issues concerning Forensic Medical Expert Examination in cases of electrical injuries and lightning stroke. The impairment of health and death caused by the effect of chemical agents (Forensic Toxicology). Medium bodily injury - legal and medical criteria (article 129 from Criminal Code) 31. Severe bodily injury - legal and medical criteria (article 128 from Criminal Code) 32. Fornication (act for the purpose of arousing or satisfying sexual desire, without copulation - articles 149 and 150 from Criminal Code). Homosexual acts (sexual intercourse or acts of sexual satisfaction with a person of the same sex - article 157 from Criminal Code). Rape (sexual intercourse with a person of the female sex - 329 article 152 from Criminal Code). Short summary for different types of examination- genetic and serological methods. Forensic Medical Expert Examination of dead body in cases of sudden natural death. Early postmortem changes –changes in the skin, changes in the eye, livor mortis, algor mortis and rigor mortis. Application of medical methods for diagnosis and treatment leading to a temporary change in consciousness. Score assessment Participation in seminars, weekly tests, essay preparation and presentation Semester exam: Yes / written and oral examination State Exam Yes Lecturer Full Professor from the Department of Epidemiology Department: Epidemiology and medicine of disastrous events. Methodology and methods of epidemiology of infectious diseases and their application in the study of massive, socially significant diseases. Epidemiologic characteristics, prevention, surveillance and control of infectious diseases. Teoretical and practical training in the field of epidemiology as a essential medical discipline. Knowledge about the mode of transmition and distribution of infectious diseases and the system of measures for prevention and control them. Knowledge of basic epidemiological characteristics of chronic mass non communicable diseases and their prevention and control. Knowledge of basic epidemiologic characteristics of non communicable diseases with massive infectious etiology and their prevention and control. Skills such as physicians to participate in solving practical problems limiting, reducing economic and social losses, elimination and eradication of infectious diseases. Theoretical knowledge about the epidemiologic features characteristic of mass non communicable diseases with such infectious etiology. Technical means and methods - autoclave, desinfection chamber - evaluation effienciency of prevention and control. Practical skills: - To make the epidemiologic history of different infectious diseases. Subject, theory and methods of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. Definition, the aim, the main tasks of epidemiology of infectious diseases and epidemiology of mass non-infectious diseases. Theory of epidemiology of infectious diseases: theory of epidemic process, epidemiologic aspects of infectious process, epidemiologic aspects of epizootic process, socio – ecosystemic dependency of diseases, molecular-genetic processes in microbial populations. Methods of epidemiology: descriptive-evalutional, observation, experimental, analysis and synthesis, molecular-genetic, molecular-biologic. Source of infection: definition of source of infection and a reservoir, a animal reservoirs, non animal reservoirs. Transmission of infectious diseases: direct and indirect contact, air born, fecal oral, blood, vector-borne transmission, derma, factors for transmition. Human behavior among family members among family members, school, work, different groups etc. Natural factors of epidemic process : geographic-climatic-meteorological and cosmic influences depending the place and time. Non infectious diseases: environmental factors, social factors, life-style related factors, iatrogenic factors. Criteria for elimination and eradication: economic considerations , social and political. Epidemiology of air born infections: Diphtheria, Scarlet fever, Meningococcial infection, Pertussis. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mode of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease, Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Season, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, 340 Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiologic process: Lethality, Seasonal features Age, Morbidity. Epidemiology of tick borne infections: Congo-Crimean fever, Q – rickettsiosis, Mediterranean Spotted fever, Lyme disease. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Definition, Etiology- antigens and resistance in environment , Incubation period, Entry site, Dischrage site, Contagious index, Source of infection, Mechanism of transmission, Immunity after disease,Characteristics of epidemiological process: Lethality, Seasonal features, Age, Morbidity. Normative documents to HealthCare Ministry –notification,Note Book for registration of infectious sicks and Note Book of contacts of sicks. Prove about careerness-indications,mode to collect samples,storage and transport of materials for laboratory examination. Purpose,tasks and meaning of physical and chemical disinfection in epidemiologic control of infection diseases. Structure and principles of work on dry sterilizer,autoclave and disinfection camera. Purpose,tasks and meaning of chemical disinfection in epidemiologic control of infectious diseases. Characteristics,advantages and disadvantages ,ways and place of exposition by groups: oxidants. Epidemiological importance of insects and arthropods as vectors of transmissive infections. Shematic presentation of the circuits of circulation of the etiological agents of plague, tularemia, Crimean hemorrhagic fever, Mediterranean spotted fever and others. Characteristic of the methods of desinsection (biological, mechanical, physical and chemical).

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In such instances order 200mcg cytotec overnight delivery, the student Chronic Disease and Disability order 100 mcg cytotec fast delivery, Subintern- must present a description of the elective ship buy cytotec 100mcg on line, and Critical Care Medicine cytotec 200mcg without a prescription. Students desiring to study Hopkins Bayview Medical Center, Sinai Hos- at other institutions must make fnal pital and other affliated hospitals. Students arrangements through the Offce of the are introduced to practical clinical problems Registrar of the Johns Hopkins University through instruction and participation in a School of Medicine. Elective courses avail- Students visiting other institutions and able in every department range from direct those who devote their free time to elective participation in current biomedical research courses in this institution will be held respon- to advanced clinical work. Many clerkships sible for profcient work just as in the case of and elective courses may be taken during the the required subjects of instruction. Formal registration for elective quarter pro- In addition to the advanced clinical clerk- grams is through the Offce of the Registrar ships noted above, students are required to of the School of Medicine. The elective work complete a 2-week course in the Fourth Year for the Second through the Fourth Years is designed to refresh clinical skills and prepare denoted by the symbol E (e. Such courses are listed numerically by Internship and Residency and Preparation for department or sub-department. The Elective of the Fourth Year, and includes simulation- Book, an up-to-date description of all elective based training, advanced cardiac life sup- opportunities, is maintained by the Registrar port, and advanced communication skills. Between the First and Second Years there Required Work is a summer vacation of eight to nine weeks The required departmental work for each when students may engage in research or course and basic clerkship is usually regard- other studies. It may be offered and graded as schedules to include, between the start of the a single course, although the catalogue may fourth quarter of the Second Year and gradua- indicate various course elements that com- tion in May of the Fourth Year, 7 quarters and prise the whole. Formal registration for all 2 weeks of required clinical clerkships and 20 required courses must be made through the weeks of clinical elective work; two additional Registrar of the School of Medicine. The total number of students in each class of the regular four year program is 120. A recom- mittee on Admissions is concerned solely mendation from the applicant’s college pre- with the quality and scope of an applicant’s medical committee or an offcially designated undergraduate educational experience. If the college feld of concentration for undergraduate stud- does not have a premedical advisor or pre- ies and the selection of additional courses in medical committee, two letters of recom- the sciences and mathematics should be the mendation are required from science faculty choice of the student and will not affect the members in science departments who have admissions process. Offcial institution on the list entitled “Accredited Insti- transcripts are required from all colleges tutions of Postsecondary Education,’’ autho- attended outside the United States and Can- rized and published by the American Coun- ada. Extension or eve- gible for the fnancial aid program from Johns ning courses taken in fulfllment of premedi- Hopkins University School of Medicine due cal course requirements are not acceptable to federal restrictions on the use of a large unless they are identical to courses offered in percentage of the loan funds which support the college’s regular academic program. Because of these limitations, aration in foreign universities, in most cases, qualifed students will be issued conditional must be supplemented by a year or more of acceptances into the School of Medicine course work in an accredited United States under the following terms: on or before July 1 university. Each appli- dent must provide an escrow account or a four cant must have received the B. A list of major United States bank in the favor of Johns specifc pre-medical course requirements Hopkins University. In order to assess fcient to meet all tuition, mandatory fees and the classroom performance of an applicant, living expenses for the anticipated period of the Committee on Admission requires that all enrollment. The current escrow requirement of the coursework submitted in fulfllment of is $270,000. In the event of tuition increases admission requirements must be evaluated for future years, accepted students will be on the basis of a traditional grading system. Details of fnancial requirements will be bers or letters to indicate the comparative included in letters of acceptance. Following receipt received a grade of Pass/Credit for any of the of all required credentials, the committee on specifed premedical course requirements, admission will review applications and make the instructor must supply, in writing, a state- interview decisions. Applicants selected for ment evaluating the student’s performance in interview will be notifed by the committee. Students admit- the applicant lives at some distance from Bal- ted to the School of Medicine on a conditional timore. The student should attain a basic understanding of the structure and function of the mammalian cell. Individuals who have completed their studies in biology more than 4 years prior to their application are strongly advised to take a one semester advanced mammalian biology course. The student should have knowledge of chemi- cal equilibrium and thermodynamics, acid/base chemistry, the nature of ions in solution and redox reactions, the structure of molecules with special emphasis on bioorganic compounds, reaction rates, binding coeffcients, and reaction mechanisms involved in enzyme kinetics. Also important is a basic understanding of the structure of nucleic acids including how they store and transfer information. Applicants with advanced placement in general chemistry must take one additional semester of advanced chemistry with lab. Effective communication skills are essential and candidates must be profcient in spo- ken and written English and be able to communicate well. Advanced Placement credit for calculus, acceptable to the student’s undergraduate college, may be used in fulfllment of the math requirement. Advanced Placement credit for physics, acceptable to the student’s undergraduate college, may be used in fulfllment of the physics requirement. Those desiring additional information and must be paid on-line when submitting should contact the Admission’s Offce. Specifc details are available in the secondary appli- We do not accept applications for early cation instructions. Specifc questions dents to diversify their educational and life about applying to the School of Medicine experiences as they prepare for a career may be answered by calling the Admissions in medicine. Information may approved for a period of one to three years also be requested by writing to: Committee to pursue international fellowships (Rhodes, on Admissions, Johns Hopkins University Rotary, Marshall, Watson, Fulbright scholar- School of Medicine, 733 N. Admit- Accepted Applicants: It is the policy of ted applicants who are interested in deferring the Johns Hopkins University School of their matriculation into the frst year class, Medicine to require criminal background must submit a written request by May 1 for investigations on accepted students in review and approval by the Deferral Commit- any professional or graduate program tee. Please Medical Education program sponsored contact the Admissions Offce for further by Johns Hopkins, and other clinical information. Provided Applicants to the Johns Hopkins University with the Johns Hopkins application for the School of Medicine are considered without M. Under the section folio, such as refective writing, credentialing, “Graduate Programs’’ in this catalogue, those and patient care documentation. This portfo- departments which offer study leading to a lio is reviewed twice a year with the College Ph. Compe- necessary letters of recommendation, they tition between students for grades per se is will be reviewed by the Committee on Admis- strongly discouraged, emphasis being placed sion, the M. Committee, and by the instead on giving each student full opportu- appropriate graduate department. If admit- nity to develop his or her particular abilities ted to both degree programs, the student will and interests. Students initially accepted Longitudinal Clerkship and Transition to the for only one of the two degrees are eligible to Wards, and continuing with subsequent clini- reapply for study towards the other at a later cal clerkships and electives, grades are des- time. Honors is awarded to a student who Advanced Standing has been consistently outstanding in scholar- ship and professionalism. Due to space limitations, the School of Medi- The grade of Fail is used if a student does cine is unable to admit transfer students. Persons who have already received the If a student exhibits a marginal perfor- degree of Doctor of Medicine elsewhere will mance in which the minimal performance not be admitted as candidates for that degree expectations of a course or clerkship are met, from the Johns Hopkins University. Remedial work will not allow an Examinations Unsatisfactory grade to be remediated higher Grading at the Johns Hopkins University than a Pass. If the remedial work for a failing School of Medicine is not viewed as an end grade requires repetition of the entire course in itself. Although grades are an appropriate or clerkship, the resulting grade will refect means for monitoring and recording achieve- the student’s performance on the retaken ment and progress towards the M. Students who do not complete all required Students at Johns Hopkins receive contin- components of a course are given an Incom- ual feedback on their progress toward achiev- plete. When students are unable to complete ing the educational objectives of the curricu- requirements because of illness or other com- lum. For the knowledge-based courses in pelling personal circumstances, they should the frst 20 months of the curriculum, written promptly contact the Associate Dean for Stu- assessments occur approximately every 2-3 dent Affairs in order to request permission weeks; students also receive narrative feed- for a temporary interruption of studies. The back from course and small group leaders for Associate Dean for Student Affairs will assist each course block.