By M. Pyran. Tulane University.
It is uncommon for the virus to become active again in someone who has had a previous infection and for the virus to cause infection in the unborn child best nitroglycerin 2.5 mg. You may want to consider reducing your contact with children cheap 6.5 mg nitroglycerin amex, especially those under 2 1/2 years of age buy generic nitroglycerin 6.5mg. About 50% of all adults have been infected sometime during childhood or adolescence. The most common illness caused by parvovirus B19 infection is “fifth disease,” a mild rash illness that occurs most often in children. The ill child usually has an intense redness of the cheeks ( a“slapped- cheek” appearance) and a lacy red rash on the trunk and limbs. Recovery from parvovirus infection produces lasting immunity and protection against future infection. An adult who has not previously been infected with parvovirus B19 can be infected and have no symptoms or can become ill with a rash and joint pain and/or joint swelling. It goes away without medical treatment among children and adults who are otherwise healthy. Joint pain and swelling in adults usually goes away without long- term disability. During outbreaks of fifth disease, about 20% of adults and children are infected without getting any symptoms at all. However, the disease can be severe in children with sickle cell anemia, other blood disorders, or weakened immune systems and in pregnant women. Usually, there are no serious complications for a pregnant woman or her baby following exposure to a person with fifth disease. About 50% of women are already immune to parvovirus B19, and these women and their babies are protected from infection and illness. Even if a woman is susceptible and gets infected with parvovirus B19, she usually experiences only a mild illness. Likewise, her unborn baby usually does not have any problems because of the parvovirus B19 infection. Sometimes, however, parvovirus B19 infection will cause the unborn baby to have severe anemia and the woman may have a miscarriage. This occurs in less than 5% of all pregnant women who are infected with parvovirus B19 and occurs more commonly during the first half of pregnancy. There is no evidence that parvovirus B19 infection causes birth defects or mental retardation. If you have been in contact with someone who has fifth disease or you have an illness that might be caused by parvovirus B19, you may wish to discuss your situation with your healthcare provider. Your healthcare provider can do a blood test to see if you have become infected with parvovirus B19. A blood test for parvovirus B19 may show that you: Are immune to parvovirus B19 and have no sign of recent infection. There is no universally recommended approach to monitor a pregnant woman who has a documented parvovirus B19 infection. Some healthcare providers treat a parvovirus B19 infection in a pregnant woman as a low-risk condition and continue to provide routine prenatal care. Other healthcare providers may increase the frequency of doctor visits and perform blood tests and ultrasound examinations to monitor the health of the unborn baby. If the unborn baby appears to be ill, there are special diagnostic and treatment options available. Your obstetrician will discuss these options with you and their potential benefits and risks. Is there a way I can keep from being infected with parvovirus B19 during my pregnancy? Frequent handwashing is recommended as a practical and probably effective method to reduce the spread of parvovirus. Excluding persons with fifth disease from work, childcare centers, schools, or other settings is not likely to prevent the spread of parvovirus B19, since ill persons are only contagious before they develop the characteristic rash. This group of viruses includes polioviruses, coxsackieviruses, echoviruses, and enteroviruses. Most enteroviral infections are asymptomatic or are manifest by no more than minor malaise. The disease usually begins with a fever, poor appetite, malaise (feeling vaguely unwell), and often with a sore throat. The rash is usually located on the palms of the hands and soles of the feet; it may also appear on the buttocks and/or genitalia. Rarely, the patient with coxsackievirus A16 infection may also develop “aseptic” or viral meningitis, in which the person has fever, headache, stiff neck, or back pain, and may need to be hospitalized for a few days. In 1998, a major outbreak in Taiwan caused nearly 130,000 cases and resulted in 78 deaths, nearly all of them in children under 5 years old. Newborns without maternal antibody who acquire this infection are at risk for serious disease with a high mortality rate. Therefore, pregnant women are frequently exposed to them, especially during summer and fall months. Most enteroviral infections during pregnancy cause mild or no illness in the mother. Although the available information is limited, currently there is no clear evidence that maternal enteroviral infection causes adverse outcomes of pregnancy such as abortion, stillbirth, or congenital defects. However, mothers infected shortly before delivery may pass the virus to the newborn. Babies born to mothers who have symptoms of enteroviral illness around the time of delivery are more likely to be infected. Most newborns infected with an enterovirus have mild illness, but, in rare cases, they may develop an overwhelming infection of many organs, including the liver and heart, and die from the infection. The risk of this severe illness in newborns is higher during the first two weeks of life. So throughout the pregnancy, practice good personal hygiene to reduce the risk of exposure to enteroviruses: Wash your hands with soap and water after contact with diapers and secretions from the nose or mouth. Persons who are newly infected with hepatitis B virus (acute infection) may develop symptoms such as loss of appetite, tiredness, stomach pain, nausea, vomiting, dark (tea or cola-colored) urine, light- colored stools, and sometimes rash or joint pain. If the virus is present for more than six months, the person is considered to have a chronic (lifelong) infection. As long as persons are infected with the hepatitis B virus, they can spread the virus to other people. Approximately 25% to 50% of children infected between the ages of 1 and 5 years will develop chronic hepatitis. However, some people do develop non-specific symptoms at times when the virus is reproducing and causing liver problems.
Human cases of the disease have been seen in Colombia discount 2.5 mg nitroglycerin overnight delivery, Costa Rica order nitroglycerin 2.5 mg, Ecuador discount nitroglycerin 6.5mg amex, El Salvador, Honduras, Mexico, and Peru (in Cajamarca and along the coast north of Lima). In Ecuador, between 1921 and 1969, a total of 511 cases were reported, and between 1972 and 1976, there were 316 cases in four provinces of that country, most of them in the province of Manabí (Arzube and Voelker, 1978). In a study carried out in northwestern Ecuador, 43% of the crayfish examined were found to be infected, and 62% of the streams proved to be harboring infected crustaceans (Vieira, 1992). About 20 cases have been diagnosed in Cajamarca, Peru, and some have also been reported in Mexico. A long time elapses between the ingestion of metacercariae and the appearance of symp- toms, though the duration of this period is variable. The parasites can cause damage as they migrate toward the lungs and seek a mate in the pleural cavity, while they are encysted in the lungs, and sometimes when they become lodged in ectopic sites. Indeed, experimental studies in dogs have shown that migration toward the lungs can produce considerable damage. The prominent symptoms of pulmonary paragonimiasis are chronic productive cough, thoracic pain, blood-tinged viscous sputum, and sometimes fever (Im et al. Small numbers of parasites in the lungs do not significantly affect the health of the patient and do not interfere with routine activity. About two-thirds of the shadows revealed by radi- ography are located in the middle and lower portions of the lungs; they are rarely seen in the apex. According to reports of cases in the Americas, the brain has also been parasitized by species other than P. In the Republic of Korea, which is a hyperendemic area, an estimated 5,000 cases of cerebral paragonimiasis occur each year. The symptomatology is similar to that of cerebral cysticercosis, with cephalalgia, convulsions, jacksonian epilepsy, hemiplegia, paresis, and visual disorders. Abdominal paragonimiasis produces a dull pain in that region, which may be accompanied by mucosanguineous diarrhea when the intestinal mucosa is ulcerated. In other localizations, the symptomatology varies depending on the organ affected. The subcutaneous nodular form, characterized by intense eosinophilia, is pre- dominant in infections caused by P. In addition to migratory subcutaneous nodules, the most common manifestations of P. Cases of ectopic paragonimi- asis in the brain, liver, and perivesical and cutaneous fat have been observed in Latin America. Twelve cases of cutaneous paragonimiasis occurred in the same family in Ecuador; in addition, there was a single isolated case in that country and another in Honduras (Brenes et al. The symptoms are similar to those of human pulmonary paragonimiasis, with coughing and bloody sputum. In the laboratory, trematodes appear in the lungs of dogs 23 to 35 days after exper- imental infection. The parasitosis begins as pneumonitis and catarrhal bronchitis, which are followed by interstitial pneumonia and the formation of cysts. Transmission results from the ingestion of raw or undercooked crustaceans, raw crabs marinated in wine (“drunken crabs”), or crus- tacean juices. Paragonimiasis is a public health problem in countries where it is cus- tomary to eat raw crustaceans or use them for supposedly therapeutic purposes. However, the disease is a problem in Japan as well, even though crustaceans are well cooked before they are eaten; in this case, the main source of infection is hands and cooking utensils contaminated during the preparation of crustaceans. It is possible that man may also become infected by eating meat from animals that are paratenic hosts carrying immature parasites, as evidenced by cases on the island of Kyushu, Japan, that occurred following the consumption of raw wild boar meat. The hypothesis that there are paratenic hosts is reinforced by the fact that paragonims have been observed in carnivores such as tigers and leopards that do not eat crus- taceans (Malek, 1980). Transmission is always cyclic—the infection cannot be transmitted directly from one definitive host to another. The parasite must complete its natural cycle, and in order for this to happen the two intermediate hosts must be present—appropriate species of both snails and crustaceans. In endemic areas of eastern Asia, the human infection rate is high enough that man can maintain the infection cycle alone through ongoing contamination of freshwater bodies with human feces. In such areas, the role of animal definitive hosts may be of secondary importance. This experience bears out the importance of human infection in maintaining the endemic. On the other hand, in several parts of Africa, Latin America, and Asia, wild animals are more important than man or domestic animals in maintaining the infection cycle. Diagnosis: In endemic areas, paragonimiasis may be suspected if the typical symptoms are present and the consumption of raw or undercooked crustaceans is a local custom. Radiographic examination is useful, but the findings may be negative even in symptomatic patients. Moreover, interpretation of the results can be difficult in nonendemic areas because the images may be mistaken for those of tuberculosis. Specific diagnosis of pulmonary paragonimiasis is based on the identification of eggs in sputum, fecal matter, pleural effusions, or biopsies. The eggs are reddish brown, operculate, and enlarged at the end opposite the operculum. It is important to differentiate the eggs of Paragonimus from those of other trematodes, as well as cestodes of the order Pseudophyllidea, such as Diphyllobothrium. The cerebral forms can be mistaken for tumors or cysticercosis, and the cutaneous forms, for other migratory larvae—hence the interest in developing indirect tests. An intradermal test that was only weakly sensitive and of questionable specificity was widely used in the past for epidemio- logic purposes. In a province of China, a 1961 study found that 24% of the persons examined had positive skin tests, and almost half of those cases were confirmed. This assay can distinguish infections caused by different species of Paragonimus (Kong et al. In addition, the polymerase chain reaction is being used to diagnose parago- nimiasis (Maleewong, 1997). Control: In endemic areas, control efforts should be directed at interrupting the infection cycle by the following means: a) education of people to prevent the con- sumption of raw or undercooked crabs or crayfish; b) mass treatment of the popula- tion to reduce the reservoir of infection; c) elimination of stray dogs and cats for the same purpose; d) sanitary disposal of sputum and fecal matter to prevent the con- tamination of rivers; and e) controlling snails with molluscicides in areas where this approach is feasible. For a control program to be effective, it should encompass the entire watershed area and adjacent regions. In Latin America, where the transmission cycle appears to occur predominantly in wildlife and where human cases are sporadic, the only practical measure is to edu- cate and warn the population about the danger of eating raw or undercooked crus- taceans. A study in China investigated the possibility of destroying metacercariae in crustaceans by irradiation with cobalt-60.
Mills S cheap nitroglycerin 2.5mg mastercard, Bone K: Principles and practice of phytotherapy buy cheap nitroglycerin 6.5 mg on-line, Edinburgh purchase nitroglycerin no prescription, 2000, Churchill Livingstone. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Castleman M: Herbal healthwatch: minty relief for irritable bowel syndrome, Herb Q 86:8-9, 2000. Pittler M, Ernst E: Peppermint of for irritable bowel syndrome: a critical review and meta-analysis, Am J Gastroenterol 93:1131-5, 1998. Khosh F: A natural approach to irritable bowel syndrome, Townsend Lett Doc Pat 204:62-4, 2000. Extraintestinal manifestations include arthritis, skin rashes, ocular disorders, and anemia. In an attempt to avoid side effects from prescribed medicines, as a result of unsat- isfactory outcomes, or in search of a cure, patients may try complementary medicine alternatives. Studies suggest that around four in 10 patients have tried alternative health therapies for their gastrointestinal problems. One possible explanation is an immune-based inflammatory response of bowel mucosa to neurotransmit- ters and neurohumoral peptides. Because inflammation is fundamental to the pathogenesis of both ulcerative colitis and Crohn’s disease, the aims of intervention are to dampen the inflammatory response and improve nutri- tion of the epithelial lining. Plasma levels of antioxidant vitamins (ascorbic acid, alpha-and beta-carotene, lycopene, and β- cryptoxanthin) are all significantly lower in patients with Crohn’s disease than in control subjects. Supplementation with ω-3 fatty acids and antioxi- dants may dampen the inflammatory response, and dietary choice and bowel microflora can affect production of butyrate, the preferred fuel for colonic epithelium. Short-chain fatty acids, produced by colonic bacterial fermentation of dietary fiber, play a pivotal role in the integrity and metabolism of colonic mucosa. Butyric acid, the preferred fuel for colonic epithelial cells, has a trophic effect on colonic epithelium. Because oxidation of ω-butyrate gov- erns the epithelial barrier function of colonocytes, the functional activity of short-chain acyl-CoA dehydrogenase may be critical in maintaining colonic mucosal integrity. Sulfur is essential for ω-butyrate formation, and its production aids in the disposal of hydrogen produced by colonic bacteria. Patients with ulcerative colitis have enhanced sulfate metabolism, and removal of foods rich in sulfur amino acids—such as milk, eggs, and cheese—has therapeutic benefits. In controlled clinical trials, butyric acid enemas have been found to be beneficial in the treatment of ulcerative colitis. Supplementation with ω-3 fatty acids plus antioxidants significantly changes the eicosanoid precursor profile and may lead to the production of eicosanoids with attenuated proinflammatory activity. Results of a 12-month study suggested that 8 weeks of zinc supplementation (110 mg of zinc sul- fate three times daily) could resolve altered bowel permeability in patients with Crohn’s disease in remission. Chamomile and meadowsweet may be useful in patients with mucus in the stool, which suggests underlying inflammation. Small nonrandomized studies suggest that Boswellia serrata may be effec- tive in the treatment of ulcerative colitis. Heuschkel R, Afzal N, Wuerth A, et al: Complementary medicine use in children and young adults with inflammatory bowel disease, Am J Gastroenterol 97:382-8, 2002. Babidge W, Millard S, Roediger W: Sulfides impair short chain fatty acid beta- oxidation at acyl-CoA dehydrogenase level in colonocytes: implications for ulcerative colitis, Mol Cell Biochem 181:117-24, 1998. A novel neutraceutical therapeutic strategy for ulcerative colitis, Digestion 63:S60- S677, 2001. Belluzzi A, Boschi S, Brignola C, et al: Polyunsaturated fatty acids and inflammatory bowel disease, Am J Clin Nutr 71:339S-342S, 2000. Langmead L, Dawson C, Hawkins C, et al: Antioxidant effects of herbal therapies used by patients with inflammatory bowel disease: an in vitro study, Aliment Pharmacol Ther 16:197-205, 2002. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Pinn G: The herbal basis of some gastroenterology therapies, Aust Fam Physician 30:254-8, 2001. Treatment can be problematic because the recommended duration for hyp- notic drug use is 4 weeks. The time limitation advocated for hypnotic drug use has been set to prevent habituation and the withdrawal symptoms after long-term use. Persons with insomnia have difficulty getting to sleep and staying asleep, and they wake unrefreshed. Acute stress and environmen- tal disturbances are the most common causes of transient and short-term insomnia. Chronic insomnia is often associated with medical conditions, psychiatric problems such as depression, or persistent psychophysiologic disorders such as inadequate sleep hygiene. This involves creating external and internal environments that are conducive to sleep. Except for a physiologic mid-afternoon dip in alertness, the circadian rhythm of sleepiness and alertness promotes a daily cycle of nighttime sleep and daytime alertness. Normal sleep consists of four to six behaviorally and electroencephalo- graphically defined cycles. It initially reduces sleep latency and decreases arousals but then causes increased waking in the second half of the night. Caffeine may reduce sleep latency, but it fragments sleep, causing sleep disruption in the latter part of the night. Milk is a rich source of tryptophan and nicotinic acid, one of the B group of vitamins that influences the conversion of tryptophan to serotonin. The belief that drinking a warm glass of milk before going to bed will help one sleep is biochemically plausible. Single low doses of melatonin, provided that they mimic the nocturnal phys- iologic concentration of this hormone, exert immediate sleep-inducing effects. L-Tryptophan is the amino acid precursor to serotonin, the neurotrans- mitter thought to induce sleep. A dose of 1 to 2 g of L-tryptophan has been reported to halve sleep latency and decrease waking time. The sleep patterns of insomniacs taking tryptophan more closely Chapter 32 / Insomnia 341 resemble those of normal sleepers than those of untreated insomniacs or per- sons taking sleeping tablets. In fact, the only change noted in the architecture of tryptophan-assisted sleep is an increase in duration of the third and fourth stages of slow-wave sleep. The immediate precursor of sero- tonin, 5-hydroxytryptophan (10 mg), is currently being used as a sleep aid, a treatment for depression, and a weight loss aid. When tryptophan is taken with vitamin B6 (50 mg) and niacinamide (500 mg), the conversion of tryptophan to serotonin is favored. Controlled clinical trials suggest that deficiency of potassium or thiamine may contribute to insomnia.
In the symp- tomatic cases purchase generic nitroglycerin from india, cough and thoracic pain lasting a month or more have been reported buy generic nitroglycerin line, along with occasional hemoptysis buy nitroglycerin 6.5 mg low cost, fever, malaise, chills, and myalgia. Subcutaneous dirofilariasis and, frequently, subconjunctival dirofilariasis is due to D. The lesion is generally a subcutaneous nodule or submucosal swelling which may or may not be nodular. In general, a single parasite is responsible for the lesion, and on some occasions, it has been retrieved alive. In a few cases, microfilariae have been observed in the uterus of the parasite, and in just one case, in the patient’s blood (Marty, 1997). The lesion is inflammatory, with accompanying histiocytes, plasmocytes, lymphocytes, and abundant eosinophils. The infection must be differentiated from sarcoidosis, ruptured dermoid cyst, infectious abscesses, neoplasms, and idiopathic pseudotumors (Kersten et al. Some 56 cases of human intraocular filariasis in which the parasite was a specimen of a variety of species, predominantly nonzoonotic worms such as L. The cases of zoonotic onchocerciasis in North America were manifested as fibrotic nodules on the wrist tendon and, in one case, the nodule was embedded in the cornea (Burr et al. The Disease in Animals: Dogs and cats do not seem to suffer symptoms of infec- tion due to subperiodic B. Dogs develop lymphangitis with fibrotic lym- phadenopathy similar to that of man (Snowden and Hammerberg, 1989). In cases of more intense or protracted infections, the living or dead filariae cause stenosis of the pul- monary vessels, obstructing the flow of blood. The most prominent signs are chronic cough, loss of vitality, and, in serious forms, right cardiac insufficiency. Chronic passive conges- tion can develop in several organs and produce ascites; thromboses caused by dead parasites can lead to pulmonary infarctions, resulting in sudden death. The acute hepatic syndrome consists of obstruction of the vena cava inferior by a large num- ber of adult parasites that matured simultaneously, with consequent acute conges- tion of the liver and kidneys, hemoglobinuria, and death in 24 to 72 hours. Source of Infection and Mode of Transmission: The reservoirs of subperiodic brugiasis, which occurs in the wooded and swampy regions of Southeast Asia, are monkeys, cats, and wild carnivores. High rates of infection have been found in the monkeys Presbytis obscurus and Macaca irus. The infection is transmitted by mosquitoes of the genus Mansonia from animal to ani- mal, from animal to human, and from human to human. The maximum concentra- tion of microfilariae in the blood occurs at night to coincide with the nocturnal feed- ing habits of the vectors. Although Mansonia mosquitoes usually feed outside houses, they have also been found inside them, as is demonstrated by the fact that the infection occurs in children. Man is an accidental host of zoonotic filariae (with the exception of subperi- odic B. Role of Animals in the Epidemiology of the Disease: Of the large number of filariae species that exist in nature, only eight have fully adapted to man, and their transmission is exclusively or mainly person to person (see Etiology). The other species of filariae are parasites of animals, affecting man only occasionally and thus not constituting a public health problem. One exception is subperiodic Brugia malayi, which is an important pathogen for man. The most common techniques are the blood smear stained with Giemsa stain, the Knott concentration, and Millipore filter concentration. Since microfilaremia takes many months to appear after infec- tion, ganglion biopsy can be useful for early diagnosis. In man, diagnosis of pulmonary or subcutaneous dirofilariasis is made by mor- phologic examination of parasites obtained through biopsy or surgery. In dogs and cats, diagnosis is made by identifying microfilariae in the blood, using a smear, the modified Knott method, or Millipore filters. Consequently, it is possible to differentiate the respective infections serologically (Simon et al. The polymerase chain reac- tion has also been used successfully to differentiate infections caused by D. Mass therapeutic treatment of human communities has also been successfully used to decrease the source of infection for the vectors. Control of subperiodic brugiasis is more difficult because of the ecologic character- istics of the endemic area and because of the abundance of wildlife reservoirs. In India and Sri Lanka, population levels of the intermediate host and vector of subpe- riodic B. The drug should not be given to dogs with microfi- laremia, as it can destroy the microfilariae and produce anaphylactic shock in sensi- tized animals. The other human zoonotic filariases are very rare, so individual protective measures against vectors are sufficient. A new zoonosis of the cerebrospinal fluid of man probably caused by Meningonema peruzzii,a filaria of the central nervous system of Cercopithecidae. Importance in France of the infestation by Dirofilaria (Nochtiella) repens in dogs. Recent increase of human infections with dog heart worm Dirofilaria immitis in Japan. Human dirofilariasis due to Dirofilaria (Nochtiella) repens:Areview of world literature. These parasites belong to the families Cheyletiellidae, Dermanyssidae, and Macronyssidae. In the family Cheyletiellidae, only the genus Cheyletiella is of importance for present purposes. The members of this genus are obligate ectoparasites of lago- morphs, dogs, cats, wild animals, and, occasionally, man. Each palp has a claw directed toward the mouth, and at the end of the legs is a double row of hairs instead of suckers. The hexapod larvae develop within the egg and then go through two nymphal stages before becoming adults. They are superficial para- sites of the skin and fur and do not dig galleries into the host. Off the host, the adult female and the eggs can survive up to 10 days in a cool place, but the larvae, nymphs, and adult males are less resistant and die in about 2 days in the open environment. Because of their appearance and the way they move, they are popularly referred to as “walking dandruff. The zoonotic species are Dermanyssus gallinae,aparasite of chickens, turkeys, pigeons, canaries, and wild fowl, and Liponyssoides (Allodermanyssus) sanguineus,found on small rodents.
The Private Sector’s Role in Health Supply Chains: Review of the Role and Potential for Staff rest areas Private Sector Engagement in Developing Country Health Supply Chains discount 6.5 mg nitroglycerin otc. West Sussex nitroglycerin 6.5mg with visa, England: John reduces fre hazards and the risk of vermin infestation in the Wiley & Sons buy generic nitroglycerin 2.5 mg line. Guidelines for the Storage of Essential Medicines dressings should be available to treat workers who sufer and Other Health Commodities. Is a • What was the value of inventory at the beginning delivery, collection, or mixed system in use? Stores management and staffing Storage conditions • does an operations manual adequately describe cur- • Are medicines zoned in correct combinations of rent procedures and responsibilities? Guidelines for Establishing or Improving Primary and Distribution Activities of Faith-Based Organizations in Sub-Saharan Intermediate Vaccine Stores. The 25 member Medical Council consists of 13 non-medical members and 12 medical members. It has a statutory role to protect the public by promoting the highest professional standards amongst doctors practising in the Republic of Ireland. This includes the responsibility to “better ensure the education [and] training of medical practitioners…” The Act entrusts Council with a wide range of complex functions in medical education and training. However, the majority of these functions can be expressed simply, in terms of two overriding responsibilities: to set standards, and to monitor adherence to those standards. These guidelines refect the signifcance Council attaches to professionalism, not just for registered doctors, but for students too. It underlines the importance of fostering professionalism from the very beginning of a future doctor’s career. The standards of professionalism expected of students of medicine from the outset are very different to those expected of students in other felds. From a patient’s perspective, the interactions they have with those treating them in a clinical setting shape their views of the care they’ve received. The professionalism of medical students in such environments can be as important as the professionalism shown by the senior treating physician in giving patients confdence that they are being cared for to the highest possible standard. These guidelines are developed for medical schools and students, to facilitate uniformity in the teaching of professionalism throughout the medical schools and clinical settings where trainee doctors learn their skills. They are another practical expression of Council’s commitment to the central aims of promoting high standards of education, training and professionalism, and protecting the interests of the public. Their development was a collaborative process, with the view of medical schools, medical students and key partner organisations sought during a consultation process. The numerous submissions received proved an invaluable resource in producing these guidelines and promoting professionalism at the heart of the patient-doctor relationship. I would like to thank everyone who provided feedback to help better the guidelines, particularly Dr Anne Keane, for her energy, dedication and enthusiasm. The professional behaviours developed at an early stage of a doctor’s training are likely to be continued throughout their career. Through the development of these guidelines we look forward to working with medical schools and trainees to ensure there is clarity on the standards the Medical Council expects throughout a doctor’s working life, from student to specialist. Professor Freddie Wood President 7 Medical Council A Foundation For The Future Executive Summary Professionalism is central to sustaining the public’s trust in the medical profession; it is at the core of the doctor-patient relationship. Medical professionalism is the set of intrinsic values, expressed as extrinsic behaviours which underpin and justify that trust. The Council is committed to fostering a supportive learning environment to enable good professional practice and since it views professional development as a continuum, this also includes providing guidance to educational bodies and future doctors. The guidance is intended to assist medical schools in the fostering of professionalism, to support them in addressing professional defcits in undergraduates, and to provide guidance on professionalism to medical students. Good practices are already evident in these areas: the guidance is intended to complement existing processes within schools and promote consistency. Embedding professionalism in the undergraduate medical curriculum, and developing it in medical students who are right at the start of their medical career, is an investment that will pay dividends: dividends for patients, their relatives and friends, medical students themselves, members of the clinical team that will work alongside doctors, future generations of students who will be taught by doctors with high standards of professionalism who are role models, Irish medical education and training, and the health care system in Ireland. The frst part focuses on the development of high standards of professionalism, including: the principles of teaching professionalism and the “seven Rs”; methods for assessment; becoming a professional and the importance of culture and example in this process; professionalism in the context of clinical sites and among the clinical team; online professionalism; and the preparation for transition to medical practice. The second part focuses on dealing with potential professional defcits, and Student Fitness to Proceed/Fitness to Graduate. It focuses on the importance of medical schools dealing with professional defcits in the interests of patient safety; the importance of resources for Student Fitness to Proceed/Fitness to Graduate; informal support for students; and the two stages of the Student Fitness to Proceed/Fitness to Graduate process. It establishes a fundamental principle: when students do not (because they will not or cannot) demonstrate professionalism, they should not be allowed to graduate with a medical degree even if they demonstrate satisfactory academic outcomes. Medical schools already give the development of professionalism a high profle in the undergraduate medical curriculum, and there are many examples of good practice in the area. The vast majority of medical students are also conscious of the importance of being professional, and this is refected in their professional values and behaviour. These Guidelines are intended to support medical schools and students in maintaining momentum in this area. The practical development and maintenance of high standards of undergraduate professionalism requires the collective efforts of many stakeholders including medical school academic leaders, teachers and trainers, clinical training sites, students, and the medical profession both as individuals and collectively. The Council’s development and promotion of these Guidelines, and its subsequent monitoring of their implementation, is intended to underpin and reinforce medical students evolving professionalism. The Guidelines refect the signifcance Council attaches to professionalism, not just for registered medical practitioners but for students too. It underlines the importance of fostering professionalism from the very beginning of a future doctor’s career. The Guidelines are another practical expression of Council’s commitment to the central aims of promoting high standards of education, training and professionalism, and protecting the interests of the public. However, the term “medical school” is generally used in these Guidelines in the interests of readability and because it is widely understood by the intended audience. Statutory responsibility for implementing the Guidelines remains with the relevant university and with the Royal College of Surgeons of Ireland. The positive term “professionalism” is used to incorporate both an attitude and demonstrated professional behaviour. The term “professional defcit” is generally preferred to “unprofessionalism” or “unprofessional behaviour”, as “professional defcit” recognises that there are gradations in departures from expected behaviour. As students are not practising medicine in the sense of being registered and delivering clinical care, the focus of the Guidelines is their ftness to proceed to the next stage of the programme, and ultimately their ftness to graduate (the term Fitness to Practise has a statutory meaning and registration implications under the terms of the Act and is avoided). These bodies have well established policies and processes that cover issues of academic performance and ethical shortfalls including plagiarism and cheating in examinations and those will continue to apply to medical students as to every other student. The Guidelines refect that there is a particular requirement for medical students (in common with other health and social care students) to demonstrate a professionalism that is congruent with their role as apprentice practitioners. The Guidelines are intended to supplement the generic policies and processes of universities and of the Royal College of Surgeons of Ireland. However, it is important that the policies and processes of medical schools are consistent with these Guidelines, in terms of the development of good professionalism and the principles, policies and processes for dealing with professional defcits.