AEA StudentGuide 15 Finalv2

MFAC1525 Ageing & Endings A
Student Guide 2015
Session 2: TP4 2015
Contents
WELCOME TO AGEING AND ENDINGS A! .....................................................................................................4
Aims of the course ........................................................................................................................ 4
Course changes for 2015 .............................................................................................................. 4
Staff involved in the course........................................................................................................... 5
Medicine Education and Student Office (MESO) ........................................................................... 5
GENERAL INFORMATION .............................................................................................................................6
Timetable...................................................................................................................................... 6
Resources ..................................................................................................................................... 6
Evaluation ..................................................................................................................................... 6
Scenario group session preparation .............................................................................................. 6
SCENARIO 1: ALMA JONES OSTEOPOROSIS ...............................................................................................7
Schedule ....................................................................................................................................... 7
Overview ...................................................................................................................................... 8
SGS 1: Introduction to the course and the scenario ...................................................................... 9
SGS 2: Bone structure and development ..................................................................................... 12
SGS 3: Bone remodelling ............................................................................................................. 14
SGS 4: Falls in the elderly ............................................................................................................ 16
SGS 5: Fractures .......................................................................................................................... 32
SCENARIO 2: ANNIE SIMPSON ARTHRITIS ...............................................................................................36
Schedule ..................................................................................................................................... 36
Overview .................................................................................................................................... 36
SGS 6: Arthritis treatments ......................................................................................................... 37
SGS 7: Upper Limb Cases ............................................................................................................. 39
SCENARIO 3: ANDREW THEODOPOULOS BOWEL CANCER ......................................................................44
Schedule ..................................................................................................................................... 44
Overview .................................................................................................................................... 45
SGS 8: Biology of Neoplasia......................................................................................................... 46
SGS 9: Project presentations ....................................................................................................... 48
SGS 10: Colorectal cancer screening and clinical anatomy of the colon, rectum and anus........... 50
SGS 11: Cultural attitudes to death and dying ............................................................................. 55
SGS 12: Cancer Death .................................................................................................................. 57
SGS 13: Pain management and course wrap up .......................................................................... 58
Ageing & Endings A Student Guide

Session 2: TP4 2015
Page 2
ASSESSMENT ............................................................................................................................................ 60
Assessment overview .................................................................................................................. 60
Attendance ................................................................................................................................. 60
Assignments and projects offered in AEA 2015 ........................................................................... 62
Due dates for registering your choice of assignments and projects ............................................. 63
Due dates for submission of project reports and assignments .................................................... 63
Academic honesty and plagiarism ............................................................................................... 64
Exempted Assignment................................................................................................................. 64
ASSIGNMENTS .......................................................................................................................................... 65
Assignment 1: Spinal Stenosis ..................................................................................................... 65
Assignment 2: Neoplasia: Educating the Public ........................................................................... 67
Assignment 3: Immunotherapy for the Treatment of Genitourinary Cancers .............................. 70
Assignment 4: Euthanasia and Ethics .......................................................................................... 72
Assignment 5: To supplement or not? Weighing up Calcium and Vitamin D supplementation
in reducing osteoporosis risk. (QMP assignment)........................................................................ 74
PROJECTS .................................................................................................................................................. 78
Project 1: Arthroscopic Repair vs Total Knee Replacement ......................................................... 78
Project 2: Chemotherapy-Induced Peripheral Neuropathy (CIPN) ............................................... 81
Project 3: Interview with Palliative Care Patients: Metastatic Malignancy Compared with End
Stage Chronic Kidney Disease ...................................................................................................... 83
Project 4: Interview with Health Professionals Working in Palliative Care .................................. 86
Project 5: Integrating learning through developing questions for an online tutorial ................... 89

Session 2: TP4 2015
Page 3
Welcome to Ageing and Endings A!

Course Overview
The Ageing and Endings courses in Phase I have been designed to help students gain an understanding of the
health issues that arise as people age. The course addresses the biological mechanisms of degenerative disease
and how this impacts patient management and care. For many people, end-of-life issues (and choices) are
closely bound to social and cultural perspectives of life. We therefore consider these as we examine palliative
care and support for the patient and close family members as the end of life approaches.
The four themes for the Ageing and Endings courses are:
Menopause
The ageing process
Degenerative disease
Death, dying and palliative care
The AE A course emphasises the last three of these themes.
Aims of the course

These course themes are discussed using three scenarios that focus on a range of issues surrounding
osteoporosis, arthritis and cancer in ageing people. They aim to help students to:
1.
2.
3.
4.
5.
6.
7.
describe the physiological and psychological changes associated with normal ageing in both males and
females.
describe the basic anatomical organisation of the upper and lower limbs.
describe the characteristic features of synovial joints with particular emphasis on the shoulder, hip, knee
and ankle joints, and understand the changes that occur with ageing.
explain the molecular, cellular and clinical features of neoplasia, with particular emphasis on carcinoma of
the colon.
describe the structure and function of the cells of the peripheral nervous system (PNS), and explain the
consequences of peripheral nerve injury.
describe the anatomical and functional aspects of the perception of pain, and explain the mechanisms by
which analgesics ameliorate pain.
evaluate the social and ethical issues surrounding the end of life, including the issues faced by health
professionals, patients, family and carers.
Course changes for 2015

The previous offerings of this course were in 2011 and 2013. Facilitator feedback from these years indicated
that the course was very well received, challenging and encouraged student participation. The design group
have considered student and facilitator feedback in redesigning this course. In 2015, we have begun the
process of designing this course to in a blended approach. This means that we have (where possible) produced
online videos, tutorials and discussions to support learning that takes place in face-to-face sessions. Following
student feedback we have also reduced the number of student presentations in SG sessions, and increased the
feedback from discipline experts (by incorporating video feedback) for some SG tasks. These changes will be
seen in the redesigned/modified SGS 1, 2, 5, 7 and 13. In 2015, we are also trialling a blended SG session
incorporating the use of an adaptive tutorial in SGS 10. We look forward to receiving your comments and
feedback on these changes.
The 2013 course was evaluated using the university CATEI evaluation and feedback system. The results from
this evaluation demonstrated that 98% of CATEI respondents found the course challenging and interesting, and
were also satisfied with the overall quality of the course. The major issue for students was the lack of feedback
given during the course. This has been a problem for all Phase 1 courses and is partly due to the short duration
of the courses. In 2015, we have tried to address this by incorporating more expert feedback for SGS tasks,
and have also developed virtual adaptive tutorials to support learning in discipline areas. These tutorials
provide feedback, and in the case of anatomy, will support all lectures and practical sessions in the course. We

Session 2: TP4 2015
Page 4
will also release formative assessments as early as possible in the course. Most scenario group sessions have
also been designed to include quizzes we hope that this will provide students with continuous feedback
In past iterations of this course, students have found the focus on palliative care, death and bereavement
emotionally confronting. Many also found that these aspects of the course were very enlightening. We have
designed the elements of this course in consideration of the emotional stress students may encounter with
regard to the personal reflection required in this course.
Staff involved in the course

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

Department of Anatomy
School of Medical Sciences
Phone: 9385 2482
Email: k.ashwell@unsw.edu.au
Ageing and Endings Design and Implementation Group

Nalini Pather
Ken Ashwell
Jan-Maree Davis
Nicole Jones
Gary Velan
Gila Moalem-Taylor
Kerrie Arnhold
Arun Krishnan
Lila Azouz
Anatomy
Anatomy
Palliative Care
Pharmacology
Pathology
Physiology
Office of Medical Education
Physiology (Neurologist)
Faculty Education Developer
With special thanks to Rachel Thompson, Patrick McNeil, Sean ONeil, Stephen Lord, Adi Torda, Chris Hughes
and to the many individuals, including teachers, health professionals, patients and MESO staff, who have
contributed so much to the course.
Other contacts
Ethics and legal aspects
Dr Adi Torda
Email: a.torda@unsw.edu.au
Campus & Hospital Clinical skills
Dr Silas Taylor
Email: silas.taylor@unsw.edu.au
Quality of Medical Practice
Dr. Rachel Thompson
Email: rachelt@unsw.edu.au
Phone: 9385 8038
Dr Barbara Ann Adelstein

Email: b.adelstein@unsw.edu.au
Phone: 9382 8890
Student support
UNSW Counselling Service: https://www.counselling.unsw.edu.au/
Medicine Education and Student Office (MESO)

Elena Mankovskaia
Phase 1 Administrator
HelpLine
x51008
X58755
x58795
Timetable Manager
Education Support Officer
UNSW Moodle; eMed Map
Session 2: TP4 2015
Page 5
Welcome
General information
Timetable
Consult the eMed Timetable for the details of session dates, times and locations.
Resources
Resources relevant to the course can be accessed on the eMed-Map and on the Ageing and Endings A Moodle
site.
Evaluation
Periodically student evaluative feedback on both course and teaching is gathered. The UNSW's Course and
Teaching Evaluation and Improvement (CATEI) Processes are used along with student focus groups, student
forums, and at times additional evaluation and improvement instruments developed in consultation with the
Faculty of Medicine's Program Evaluation and Improvement Group. Student feedback is taken seriously, and
continual improvements are made to the course based in part on such feedback.
Significant changes to the course will be communicated to subsequent cohorts of students taking the course
through inclusion of information in student course guides, and in presentations by course convenors.
Evaluation activities across the Faculty are strongly linked to improvements and ensuring support for learning
and teaching activities for both students and staff.
The course convenors are also very keen to receive personal feedback on the course these can be conveyed
via email to the convenors.
Scenario group session preparation

Please note the following scenario group sessions have essential preparation/readings to be completed before
the session. These sessions will not make much sense to students and students will not be able to fully
participate unless they have prepared. Pre-reading is detailed in Moodle.
Week
1
2
3
4
5
6
7
Session
Activity
SGS 1
Attend the Plenary
SGS 2
Bone structure - watch video and review lecture notes
SGS 3
Bone remodelling pre-reading and presentation
SGS 4
Do QMP online tutorial and view videos
SGS 5
Pre-reading on fractures
SGS 6
Attend the Plenary.

Presentation on alternative arthritis treatments
SGS 7
Bring anatomy lecture notes and textbook (hard or soft copy)
SGS 8
Attend the Plenary
SGS 9
Prepare for project presentations
SGS 10
Watch video on colorectal anatomy and do online quiz
SGS 11
Cultural attitudes to death exercise pre-reading. Bring electronic devices for feedback
SGS 12
SGS 13
Pain management presentation
Further details on each activity, including detailed capability references, suggested readings, websites, and
information on relevant disciplines, are contained in the eMed: Map at http://emed.med.unsw.edu.au

Session 2: TP4 2015
Page 6
Scenario 1: Alma Jones Osteoporosis

Schedule
Note: This schedule is subject to change. Refer to the eMed Timetable system and email updates sent to your
UNSW email account for accurate times and locations.
Principal Teacher
Scenario Plenary 1: Alma Jones: Osteoporosis

Lecture 1: Bones and joints of the upper limb
Campus Clinical Skills Session 1: Introduction to the musculoskeletal system
Scenario Group Session 1: Introduction to the course and the scenario
Hospital Clinical Skills Session 1: Talking about pain & examination of the
hand/wrist
Lecture 2: Histology, development and growth of bone
Lecture 3: Shoulder and arm anatomy
Lecture 4: Biology of normal ageing
Lecture 5: Membrane transport and action potentials
Science Practical 1: Shoulder and arm anatomy
Scenario Group Session 2: Bone Structure and Development
Lecture 6: Metabolic bone disease
Lecture 7: Calcium metabolism
Lecture 8: Pathological Basis of Fracture Healing
Lecture 9: Forearm and hand
Science Practical 2: Bone: Normal and Abnormal
Scenario Group Session 3: Bone remodelling
Lecture 10: Action potential generation and propagation
Lecture 11: Spinal cord and spinal nerves
Lecture 12: Peripheral nervous system: Neuromuscular Transmission
Lecture 13: Falls in older people: risk factors and intervention strategies
Science Practical 3: Forearm and hand anatomy
Scenario Group Session 4: Falls in the Elderly
Lecture 14: Vestibular system
Lecture 15: Pain neurotransmission
Science Practical 4: Sensory Nerve Conduction and Carpal Tunnel Syndrome
Lecture 16: Skeletal muscle physiology
Lecture 17: QMP: Weighing the Evidence
Tutorial 1: Action potentials
Campus Clinical Skills Session 2: Clarity when gathering information and the
musculoskeletal screening examination
Lecture 18: Brachial plexus and upper limb nerves
Lecture 19: Principle based ethics: Ethics in Practice
Science Practical 5: Brachial plexus and nerve supply of the upper limb
Scenario Group Session 5: Fractures
Online Activity : Negotiated Assignment facts and tips
Online Activity : QMP Online Tutorial 9: More about rates, ratios and risk
Online Activity : QMP Online Tutorial 10: RCTs and meta analysis
Yvonne Selecki
Nalini Pather
Silas Taylor
Nalini Pather
Silas Taylor
Patrick De Permentier
Nalini Pather
Louise Lutze-Mann
Gila Moalem-Taylor
Nalini Pather
Nalini Pather
John Eisman AO
John Eisman AO
Nicodemus Tedla
Nalini Pather
Patrick De Permentier
Gary Velan
Gila Moalem-Taylor
Elizabeth Tancred
Gila Moalem-Taylor
Stephen Lord
Nalini Pather
Rachel Thompson
Jennie Cederholm
Gila Moalem-Taylor
Gila Moalem-Taylor
Stephen Chan
Barbara-Ann Adelstein
Gila Moalem-Taylor
Silas Taylor
Nalini Pather
Adrienne Torda
Nalini Pather
Nalini Pather
Nalini Pather
Rachel Thompson
Rachel Thompson

Session 2: TP4 2015
Page 7
Scenario 1: Alma Jones Osteoporosis
Learning Activity
Overview
The scenario is based on Alma, who is in her late 60s, coming to an orthopaedic hand clinic. She lives alone and
had a fall during which she stretched out her hand to protect her but sustained a Colles fracture. This was
treated and has now healed, but she has continued to have tingling sensations in her hand with loss of
sensation on the palmar surface of the thumb. There is also the issue of underlying osteoporosis and how to
prevent further fractures.
Students completing the work associated with this scenario should be able to:
1. Explain the psychological and biological aspects of normal ageing in both males and females.
2. Discuss the causes and consequences of falls in the elderly.
3. Explain the pathophysiology of osteoporosis and its complications.
4. Describe the structure and function of the bones, muscles, vessels and nerves of the upper limb, and the
consequences of injury to branches of the brachial plexus.
5. Describe the ionic basis of the cell resting potential and the action potential.
6. Describe motor function, beginning with an action potential in a motor axon to neuromuscular
transmission and then contraction of skeletal muscle.
7. Discuss individual approaches to promoting healthy ageing.
Further details on each activity, including detailed capability references, suggested readings and websites, and
information on relevant disciplines, are contained in the eMed Map at http://emed.med.unsw.edu.au

Session 2: TP4 2015
Page 8
SGS 1: Introduction to the course and the scenario

Aims
This session aims to introduce the course and its assessments, and to help students to identify and explore the
issues raised by the scenario. It will also explore issues of calcium intake and public health programs to increase
calcium in the diet.
Key concepts for the course
Ground rules, course assessment requirements.

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

Students will need a copy of the student guide and their notes from attending the Plenary.
Process
Activity
Approx Time
1.
Introductions and housekeeping
10 mins
2.
Explore the scenario plenary and video and identify key issues
15 mins
3.
Review the scheduled learning activities
5 mins
4.
Osteoporosis risks
20 mins
5.
Calcium intake
15 mins
6.
Explore and evaluate a public health program
30 mins
7.
Review the project and assignment options
10 mins
8.
Preparation for SGS 2
2 mins
1. Introductions and housekeeping 10 mins

2. Explore the scenario plenary and video and identify key issues 15 mins
3. Review the scheduled learning activities 5 mins
4. Osteoporosis risks 20 mins
Using the knowledge the students bring to the course together with what they have learned from the Plenary
and associated lectures, the students will brain storm ideas about the risk-factors affecting bone mineral
density (BMD), and will explore the relation of low BMD to morbidity.
5. Calcium intake 15 mins
Students will evaluate the nutritional content in some sample foods and diets, with a particular focus on
calcium. Students may consult the following websites:
www.dairyaustralia.com.au/~/media/Flash/Dairy%20Australia%20Calcium%20Planner.ashx
www.abc.net.au/health/quizzestools/tools/2008/09/30/calcium_quiz.htm#.UfHHY-ArzFI
http://www.osteoporosis.org.au/about-osteoporosis
The distribution of calcium varies very markedly between foods, and certain diets pose a particular challenge to
obtaining the required daily intake (RDI) of calcium.

Session 2: TP4 2015
Page 9
As a group, rank the 10 foods in the following list by estimating their calcium content.
1. 1 cup of spinach
6. apple
2. a boiled egg
7. a serve of tofu (hard)
3. one Weet-bix (by itself)
8. cup of coffee with 20 ml of milk
4. medium tub of yogurt (plain, regular)
9. small tin of salmon (with fish bones)
5. lamb chop (grilled and trimmed)
10. cheddar cheese sandwich
Food
Size of typical serve (g)
Approximate
Calcium content
per serve (mg)
6. Explore and evaluate a public health program 30 mins

Public health programs that promote calcium intake are driven by many factors specific to the group or groups
supporting the campaign. To start out, as a class explore the campaign found on the "Healthy Bones" website:
http://www.healthybones.com.au/about-hbaw/about-healthy-bones-action-week
1.
2.
3.
4.
Is the campaign driven by predominantly political, economic or medical objectives? (What are these
objectives? Who is behind the campaign?)
Do factors of ethnicity or nationality affect this campaign?
What factors would you need to vary to make the campaign more suited to a different target audience?
(e.g., children, teachers, parents, doctors).
What is wrong with the following page on the website? http://www.healthybones.com.au
Public health messages in general, and those programmes seeking to reduce osteoporosis specifically, how do
they relate to the following issues:
1. What are the obstacles to compliance?
2. Who are the people who need to be targeted?
3. Could you sell the Asian community on increased dairy intake?
4. Who makes dietary decisions?
5. Who makes decisions about exercise?
6. What is the relationship between commercial interests and public health programmes?
Students are to investigate the types of groups that might typically support a public health program. Three
groups that might support an increase in calcium in the diet include: Health practitioners, the Government,
Dairy companies. Discuss how these groups design a program, measure its success and avoid ethical issues.

Session 2: TP4 2015
Page 10
References
Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes
http://www.nhmrc.gov.au/publications/synopses/n35syn.htm
Dietary guidelines for Australian Adults http://www.nhmrc.gov.au/publications/synopses/dietsyn.htm
National Nutrition Survey: Nutrient Intakes and Physical Measurements
http://www.abs.gov.au/AUSSTATS/abs@.nsf/0/95e87fe64b144fa3ca2568a9001393c0?OpenDocument
Nutritional determinants of bone health: a survey of Australian Defence Force (ADF) Trainees
http://www.dsto.defence.gov.au/publications/4072/DSTO-TR-1754.pdf
NIH Office of Dietary Supplements. Dietary supplement fact sheet: Calcium
http://ods.od.nih.gov/factsheets/calcium.asp
"Healthy Bones" website (http://healthybones.com.au/)
7. Review the project and assignment options 10 mins

All students must register for assignments and projects.
Assignment and Project choices should be made at or before the next scenario group session and registered
according to the instructions in the student guide. Registrations for projects or assignments with quotas must
be made by 5pm, Friday 18 September 2015. Proposals for negotiated assignments must be made by 9am
Monday, 21 September 2015. Registrations for non-quota assignments and projects must be made by 5pm,
Friday, 25 September 2015.
8. Preparation for SGS 2 2 mins
For SGS 2 students should research and review the topics related to bone listed below. As a start to
researching these topics, review lectures 1-4, and watch the following videos before coming to class:
Bone structure and cells: https://www.youtube.com/watch?v=yFJ4iswRiu4

Bone development: https://www.youtube.com/watch?v=xXgZap0AvL0
Further references for each group are also listed on the course Moodle page and in the Guide under SGS 2.
Group 1 Bone structure
Group 2 Bone development
Group 3 Bone healing
Group 4 Joints and movement

Session 2: TP4 2015
Page 11
SGS 2: Bone structure and development

Aims
This session aims to help students to understand bone: its structure and development and healing.
Key Concepts
Structure and development of bone

Healing of bone
Joints and movement
Process
Activity
Approx Time
1.
Understanding the structure of bone and its development
80 mins
2.
Battle of the Wits Quiz
30 mins
3.
2 mins
4.
Round up session
3 mins
Prework:
Students to have researched and reviewed the bone structure, development, healing and joints and
movement. Students would have also reviewed lectures 1-4, and watched the following videos before coming
to class:
Bone structure and cells: https://www.youtube.com/watch?v=yFJ4iswRiu4
Bone development: https://www.youtube.com/watch?v=xXgZap0AvL0
1. Understand the structure of bone and its development 80 mins
For the first 20 minutes, discuss each of the questions allocated to your group. Each group will then be given
15 minutes to peer-teach this content the entire group. For the peer-teaching exercise students are
encouraged to use the whiteboard, and to engage the rest of the class in discussing their topic.
Group 1: Bone structure
Differentiate between cortical/compact bone and trabecular and spongy bone. Where are these types of
bone found? What is an osteon (Haversian system)?
Consider the structure of long bone. Describe the anatomy of a typical long bone. How is the structure of
bone adapted to withstand the forces that act on it?
How does bone increase in length and diameter?
What are main concerns regarding bone health with age?
Group 2: Bone development
Which germ layer and embryological structures give rise to bone?
Briefly, differentiate between endochondral and intramembranous ossification.
How does immature and mature bone differ?
What are primary and secondary centres of ossification? Where are these for long bone?
What is rickets?
Group 3: Bone healing
Describe the stages of bone healing after a fracture (inflammation, soft callus formation, hard callus
formation and remodelling).
What is healing by primary and secondary intention?
Explain how bone formation and resorption varies with age.
What possible factors impede bone healing?

Session 2: TP4 2015
Page 12
Group 4: Joints and movement

Differentiate between fibrous, cartilaginous and synovial joints. How do they differ structurally and what
impact does this have on movement?
Describe the typical features of a synovial joint? How are synovial joints classified?
Using the shoulder joint as an example, describe the movements possible at a synovial joint.
References:
1. Standring S. (editor). (2008). Functional anatomy of the musculoskeletal system In Grays Anatomy: The
th
Anatomical Basis of Clinical Practice (40 ed., Chapter 5, pp 81-97), Churchill Livingstone.
http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr
eeText0)=UNSW_DigiTool102417
2. BME/ME 456 Biomechanics, Bone Structure
http://www.engin.umich.edu/class/bme456/bonestructure/bonestructure.htm
3. UNSW Embryology, Bone Development
http://php.med.unsw.edu.au/embryology/index.php?title=Bone_Development
4. Yang, Y.J., et al., Histology of Bone Medscape Reference
http://emedicine.medscape.com/article/1254517-overview
5. Kalfas, I.H. (2001). Principles of bone healing 1. Neurosurgical Focus, 10 (4)
http://thejns.org/doi/pdf/10.3171/foc.2001.10.4.2
6. Cannada, L.K. (2010) Fracture Classification. Orthopaedic Trauma Association
http://ota.org/media/29245/G06-FX-classification-JTG-rev-2-3-10.ppt
7. Adams, J.C. and Hamblen, D. (1999) Pathology of fractures and fracture healing in Outline of Fractures
th
including joint injuries. (11 ed., pp 3-18) Edinburgh, Churchill Livingstone.
http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=search&vl(fr
eeText0)=UNSW_DigiTool102412
8. Durschl, D.r. & Cannada, L.K. Classification of Fractures In Bucholz, R.W., et al. (2010) Rockwood and
th
Greens Fracture in adults. (7 ed. Vol 1. Chapter 2., pp 39-52). Philadelphia, Pa.: Lippincott Williams &
Wilkins.http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSW&fn=sear
ch&vl(freeText0)=UNSW_DigiTool120411
2. Battle of the Wits 30 mins
This battle of the Wits team challenge has 2 parts:
a. Preparing questions:
Each team has 10 minutes to formulate three multiple choice style questions (MCQs) on their allocated
topic. MCQ questions should have 5 options (a-e) of which only one is correct. Avoid double negative
questions. You should also be prepared to provide feedback for each of the 5 options, clearly indicating
which was the correct option. At the end of the session, these questions must be posted onto the
Moodle Forum page.
b. Battle of the Wits:
3. Preparation for SG 3 2 mins
Bone Remodelling: Four groups will present information regarding each of the key concepts to the larger
group, based on resources provided as pre-reading (10 minutes presentation plus 5 minutes for questions for
each group) References for each group are listed in Moodle and in the Guide under SGS 3.
Group 1: Physiological remodelling of bone
Group 2: Definition and impact of osteoporosis
Group 3: Diagnosis and screening for osteoporosis
Group 4: Prevention and management of osteoporosis
4. Round up session 3 mins

Session 2: TP4 2015
Page 13
SGS 3: Bone remodelling

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

Diagnosis and screening for osteoporosis
Prevention and management of osteoporosis
Process:
Activity
Approx Time
1.
Group presentations on bone remodelling
60 mins
2.
Osteoporosis quiz
45 mins
3.
Preparation for SGS 4 and session round up
5 mins
1. Group presentations on bone remodelling 60 mins

Four groups will present information regarding each of the key concepts to the larger group, based on
resources provided as pre-reading (10 minutes presentation plus 5 minutes for questions for each group)
Please post your groups presentation to the course Moodle Forum located in the Scenario Information in
Moodle
Group 1: Physiological remodelling of bone:
Questions to be addressed:
What is the normal structure of bone?
Which cell types are involved in bone growth and remodelling?
What are the physiological mediators of remodelling in bone?
What factors commonly impair bone remodelling, and might thereby increase the risk of osteoporosis?
Resources:
1. Bone Physiology: http://courses.washington.edu/bonephys/physiology.html
2. ASBMR Bone Curriculum, Bone Growth and Remodelling:
http://depts.washington.edu/bonebio/ASBMRed/growth.html
3. Invest in your bones, Beat the Break, Know and reduce your Osteoporosis Risk Factors, International
Osteoporosis Foundation
http://share.iofbonehealth.org/WOD/2007/thematic_report/WOD_07-thematic_report.pdf
Group 2: Definition and impact of osteoporosis:
What is the definition of osteoporosis? How does it differ from osteomalacia? What is osteopenia?
What is the impact of osteoporosis in Australian men and women?
What is the prevalence of common osteoporosis-related fractures in Australia?
What are the risk factors for fractures in people with osteoporosis?
Resources:
1. Bone Physiology: http://courses.washington.edu/bonephys/physiology.html
2. The Burden of Brittle Bones, Epidemiology, Costs & Burden of Osteoporosis in Australia 2007
http://www.iofbonehealth.org/sites/default/files/PDFs/white_paper_australia-23-06-08.pdf
3. Invest in your bones, Beat the Break, Know and reduce your Osteoporosis Risk Factors, International
Osteoporosis Foundation
http://osteoporosis.org.za/general/downloads/beat-the-break-report.pdf
4. Osteoporosis in Men: Why change needs to happen. International Osteoporosis Foundation
http://share.iofbonehealth.org/WOD/2014/thematic-report/WOD14-Report.pdf

Session 2: TP4 2015
Page 14
Group 3: Diagnosis and screening for osteoporosis:

What techniques are available for measuring bone density?
What are T-scores and Z-scores? How should they be interpreted?
What are the costs of osteoporosis to the Australian community?
Apart from osteoporosis, what other disorders might cause pathological fractures?
Resources:
1. ONeil, S., et al. (2004) Clinical Practice: Guidelines for the management of postmenopausal osteoporosis
for GPs, Reprinted from the Australian Family Physician Vol. 33. No.11, 2004.
http://www.racgp.org.au/afpbackissues/2004/200410/20041031oneill.pdf
2. Diagnosis of Osteoporosis with Bone Mineral Density Measurement
http://imaginis.com/osteoporosis/osteo_diagnose.asp
3. Diagnosis of Osteoporosis: http://courses.washington.edu/bonephys/opdiagnosis.html
4. Bone density: http://courses.washington.edu/bonephys/opbmd.html
Group 4: Prevention and management of osteoporosis:
1. What is the role of calcium intake in prevention of osteoporosis?
2. What is the role of Vitamin D intake in prevention of osteoporosis?
3. What is the role of exercise in prevention and management of osteoporosis?
4. What treatments are available for established osteoporosis?
5. What are the risks and benefits of the commonly used treatments for osteoporosis?
Resources:
1. Ebeling, P.R., Daly, R.M., Kerr, D.A., Kimlin, M.G. (2013) Building healthy bones throughout life: an
evidence-informed strategy to prevent osteoporosis in Australia. MJA Open 2013; 2 Suppl 1: 1. doi:
10.5694/mjao12.11363
https://www.mja.com.au/sites/default/files/issues/002_01_040213/MJA%20OpenSupplement.pdf
2. Invest in your bones, Make it or Break it How exercise helps to build and maintain strong bones, prevent
falls and fractures, and speed rehabilitation, International Osteoporosis Foundation
http://www.iofbonehealth.org/sites/default/files/PDFs/WOD%20Reports/move_it_or_lose_it_en.pdf
3. Basic prevention: http://courses.washington.edu/bonephys/opprev.html
4. ONeil, S., et al. (2004) Clinical Practice: Guidelines for the management of postmenopausal osteoporosis
for GPs, Reprinted from the Australian Family Physician Vol. 33. No.11, 2004.
http://www.racgp.org.au/afpbackissues/2004/200410/20041031oneill.pdf
5. Treatment of Osteoporosis: http://courses.washington.edu/bonephys/optreatment.html
6. Pharmacological treatments for osteoporosis:
http://osteoporosis.org.au/sites/default/files/files/oa_consumer_medicines_ed2_Aug2014.pdf
Moodle
2. Osteoporosis quiz 45 mins
Students will undertake the quiz based on the material covered in the presentations above. Questions will be
presented in a PowerPoint file, with feedback provided at the conclusion of the quiz.
Before coming to SGS 4, students are to complete the QMP Online tutorial #6, and to watch the videos
allocated as prework for SGS 4. http://web.med.unsw.edu.au/QMP/QMPTut6_2007/Tut6_Intro.htm
1) CEC - Falls Prevention - Suzanne Archer's Fall Journey (Sep, 2014). 9:26mins. Suzanne is an artist and
shares her story following a fall at home. (You may have to fast forward parts of these to get through this
all but try to get the gist). https://www.youtube.com/watch?v=5GHymbyMeCo
2) CEC - Falls Prevention - Colins Story (Jan, 2015). 3:01mins. A community case study about Colin:
(https://www.youtube.com/watch?v=MPZSiDU3-cY)
3) CEC Falls Prevention Staying Active and Health (Oct 2013):
https://www.youtube.com/watch?v=s63fFex_zZQ
Session 2: TP4 2015
Page 15
SGS 4: Falls in the elderly

Aims
To learn more about falls in the elderly and how research can be designed to find better preventive
interventions.
To help students interpret the outcomes of clinical trials by experiencing the issues involved in designing
studies.
The session aims to develop knowledge about research trials and and study design skills. This scenario
group session will teach students more about critical appraisal by getting them to think critically about
what makes a trial and what makes it work well.
This session will be backed up by an online tutorial, a lecture and a tutorial. Students are expected to have
revised the QMP online tutorial no. 5 Bias, measurement and outcomes prior to this SGS.
Key concepts
The basics of good trial design and specifically the vital factors of: bias; confounding; compliance and data
analysis (including loss to follow-up and intention to treat).
Process
Activity
Approx Time
1.
What do you know about falls in the elderly?
15 mins
2.
Design Task
65 mins
3.
Reflection and discussion
10 mins
4.
Finding out more about the impact of falls and prevention services
20 mins
5.
3 mins
Before coming to SGS 4, students are to complete the QMP Online tutorial #6, and to watch the videos
allocated as prework for SGS 4. http://web.med.unsw.edu.au/QMP/QMPTut6_2007/Tut6_Intro.htm
Students will have watched the video for Activity 4 prior to attending this session.
shares her story following a fall at home. (You may have to fast forward parts of these to get through this
all but try to get the gist). https://www.youtube.com/watch?v=5GHymbyMeCo
6) CEC Falls Prevention Staying Active and Health (Oct 2013):
https://www.youtube.com/watch?v=s63fFex_zZQ
1. What do you know about falls in the elderly? 15 mins
Students can refer to lecture notes by Prof Stephen Lord for this activity.
Student Worksheet for Activity 1

1.
What is the definition of a fall?

Session 2: TP4 2015
Page 16
2.
Why do falls happen?
3.
Why should we bother to prevent falls?
4.
What are the main modes of prevention of falls in the elderly?
2. Design task 65 mins

In this task, students will be divided into 3 groups to design a trial to determine the efficacy of a new
preventative/protective intervention for falls.
Useful resources for Activity 2:
Greenhalgh. T. (1997). How to read a paper: Assessing the methodological quality of published papers.
BMJ, 315, 305-308. Accessed 31.08.15 at:
http://er.library.unsw.edu.au/er/cgibin/eraccess.cgi?url=http://bmj.bmjjournals.com/cgi/content/full/315/7103/305h
Okasha, M. (2001). Epidemiological research. Student BMJ, 9, 261-304.
http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/search.do?vid=UNSWS&fn=search&vl
%28freeText0%29=unsw_DigiTool_Alma106715
Law, K and Howick, J. (updated 2013). Glossary of EBM terms. Centre for Evidence Based Medicine.
University of Oxford. Webpage Accessed 31.08.15 at: http://www.cebm.net/glossary/

Session 2: TP4 2015
Page 17
Activity 2:
Setting the scene
You are 3 small groups of Geriatricians based at 3 different hospitals. The many elderly people you care for are
at risk of falling and hurting themselves and these falls often have the serious outcome of a fracture of the hip
and pelvis. You have seen how appalling these fractures can be for the quality of life and life expectancy of
these patients (see Box 1). To help you focus on the key factors, you decide to proceed with a typical patient in
mind:
Mrs Myrna Travis.
Age 81, lives alone in her own free-standing house.
She fell and suffered a wrist fracture 3 years ago. After that incident she had a bone mineral density scan,
and was found to have a T-score at the hip of -2.6.
Mrs Travis weighs 55 kg and has a low BMI.
She has mild asthma and takes an inhaled glucocorticoid as a preventer.
She is otherwise healthy and is on no other regular medication.
Turning to the literature, you find that there is a lack of good trials on the three main possible interventions:
A. Group exercise (Tai chi)
B. Home intervention team
C. Home-based exercise
You are ready to commence another clinical trial, and you are good at getting research grants and like a
challenge. The next step is to meet together to begin to design the trial.
The scenario group should divide into 3 groups A, B and C with 3-5 people in each. Groups A, B and C will each
investigate an intervention for the elderly to prevent falls or reduce the risk of fractured hips resulting from a
fall.
DESIGN PROCESS:
Follow this worksheet, and work in your small group on your trial design.
You will return to the larger group at the end of each of the 3 blocks to discuss and get your answers scored
based on a PowerPoint presentation of suggested answers.
Facilitators will give points based on the PowerPoint presentation and at their or the groups discretion.
Keep a tally of the scores and decide on an overall winner at the end of the session.
The trial groups are allowed to access:
QMP online tutorials (specifically the BGDA tutorial QMP online tutorial 5 on Bias
http://web.med.unsw.edu.au/QMP/QMPTut5_2012/Tut5_Intro.htm
Links to EBM Toolkits etc in the References (listed above and in eMed) of the Online Tutorial
Box 1: Falls & hip fractures in the elderly in Victoria, Australia
From 1998 to 1999 11,845 older persons were admitted to hospital in Victoria for falls, 3,465 for fractured
hips. Older persons falls account for 124,611 bed days in a single year. Fractured hips required 49,060 of
these, and cost the government 36 million dollars annually. Unfortunately, many of these individuals will never
return home, and a substantial number of them will die needlessly as a result of their hip fractures.
Falls account for 76.8% of injury-related hospital admissions in older people (>65yrs).
Most fall injuries at home (46%)... The average length of stay in hospital...with fractured hip is 16.4
dayscosting $10,392 per admission.
Best Buys in Fall Injury Prevention, Summary 2001 Hazard, Vol: 48,1-3. Victorian Injury Scheme and
Applied Research (VISAR); VicHealth http://www.monash.edu.au/miri/research/research-areas/homesport-and-leisure-safety/visu/hazard/haz48.pdf
Cassell, E. (2001). Prevention of hospital treated fall injuries in older people. Hazard, Sept Vol. 48, 7-12.
http://www.monash.edu.au/miri/research/research-areas/home-sport-and-leisuresafety/visu/hazard/haz48.pdf

Session 2: TP4 2015
Page 18
BLOCK 1
Basic Intervention
C.
For this group, the intervention

you are investigating is an
exercise regimen based on Tai
chi. The intervention group will
be asked to attend a Tai chi
exercise
class
led
by
experienced Tai Chi instructors
(classical Yang style) three times
a week. The exercise aims to
tone and strengthen postural
muscles and improve stability
and balance.
Here, the intervention you are

investigating is assessment and
modification of the elderly
persons
home
environment,
specifically to reduce the risk of
falls within the home. An interdisciplinary home intervention
team (HIT) visit the patients home
and assess it fully using a
standardised home safety checklist.
The
HIT
makes
recommendations
for
specific
modifications (pre-agreed and
standardised) that are deemed to
improve the home for someone at
risk of falling: e.g. handrails, decluttering of floors, fixing floorcoverings and laying down non-slip
bathroom flooring.
Importantly, the HIT also teaches
participants in the use of technical
and mobility aids when necessary.
In this trial, the intervention

you are investigating is an
individually tailored home
exercise program.
The intervention group is
visited and assessed at home
by a physiotherapist. An
exercise regime is planned and
tailored individually aiming
to improve strength of postural
muscles and improve balance.
Participants are encouraged to
continue
this
exercise
regularly.
AIM:
The primary aim is to reduce the
risk of falls and fear of falling,
rather than to affect bone
mineral density.
Home-based exercise
AIM:
The primary aim is to reduce
the risk of falls, rather than to
affect bone mineral density.
AIM:
The primary aim is to reduce risk of
falls caused by safety problems in
the home environment.
In BLOCK 2 you will be able choose between 3 detailed interventions according to their cost and the
budget that you wish to expend.

Session 2: TP4 2015
Page 19
BLOCK 1
Baseline Assessment
Clinical Question
C.
Home-based exercise
Clinical Question
Clinical Question
Clinical Question
Q1. What Clinical Question are

you,
the
geriatricians,
interested in answering?
(4 points in total)
Q1. What Clinical Question are you,

the geriatricians, interested in
answering?
(4 points in total)
Q1. What Clinical Question are

you,
the
geriatricians,
interested in answering?
(4 points in total)
Baseline Assessment
Baseline characteristics are measured for all subjects and shown at the beginning of the Results section.
The authors should clearly outline the population in their trial and show any factors that might modify
the benefit of the intervention or predict adverse reactions.
The baseline measurements are important for two main reasons:
1. Clinicians reading the paper need to be able to see if the participants in the trial match the patients
in their own practice. This way they can determine the extent to which the results of the trial may
be applied to their clinical practice. This is external validity.
2. Confounders are factors that if not evenly distributed between the trial groups may mask an
intervention effect or cause an apparent beneficial effect where none exists. Potential confounding
factors are always present but randomisation of the trial groups hopefully distributes these factors
evenly between the groups.
Further reading:
Burgess, D, Gebski, V and Keech, A. (2003). EBM: Trials on trial. Baseline data in clinical trials. MJA, 179
(2), 105-107.
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0025-729X&date=2003&volume=179&issue=2&spage=105
Q2. What factors might affect the outcome of your trial? Some of these will be GENERAL and some
SPECIFIC to your trial. List suggestions (overleaf) under these two headings and note how you will
assess them.
(0.5 points per correct answer, max. 4)

Session 2: TP4 2015
Page 20
BLOCK 1
Baseline Assessment
C.
Home-based exercise
Q2. ANSWERS:
Q2. ANSWERS:
Q2. ANSWERS:
GENERAL
GENERAL
GENERAL
SPECIFIC
SPECIFIC
SPECIFIC

Session 2: TP4 2015
Page 21
Sample Size General
Choice of criteria
Choice of criteria
C.
Home-based exercise.
Selection criteria
Should be broad enough that the study results will be applicable to a large segment of the population so
that external validity is high. Inclusion criteria define your theoretical and trial population subjects.
Your inclusion criteria for this trial might be:
1. Australian citizen or permanent resident dwelling in the region of study.
2. Age > 80 years.
3. At least one other risk factor for falling (see list your specific factors in Q2 might be
appropriate).
However, you need to exclude people with conditions that would bias the result or invalidate the trial
(e.g. if bedbound!). These are exclusion criteria.
Q3. What are the major exclusion criteria? (1 point for each, max. 4)
Q3. ANSWERS
Q3. ANSWERS
Q3. ANSWERS
Sample size
This depends on the size of the response that you are likely to see with the intervention and the size of
the difference between the intervention and control groups that you think will be statistically and
clinically significant.
The Statistical Significance:
When analysing results from a study with a large sample size, a statistical test is more likely to show a
level of statistical significance even if the intervention effect is small. A trial with a small sample size will
prove harder to show a statistical significance, even if there is a real and substantial intervention effect.
Clinical Significance:
This requires you to decide how large a reduction in the rate of falls is likely to make it worthwhile for
this intervention to be used. The answer to this question may depend on who you make the decision
for: as a GP for an individual patient whose financial and other circumstances will vary; as a
recommendation to Government to fund a program for the elderly population in general who live at
home etc.
By requiring subjects for inclusion in the study to have at least one risk factor for falls, you are able to
reduce the sample size while maintaining a reasonably high rate of falls in the control group and so
achieving the same statistical significance as required for a larger group of subjects where that didnt
require a risk factor for falls.

Session 2: TP4 2015
Page 22
Study Structure
BLOCK 2
C.
Home-based exercise
A randomised controlled trial (RCT) is the ideal study design for investigating this type of question. RCTs
can be run as a parallel or a crossover study.
Parallel trial
Study Structure
Cross-over Trial
Q4. What type of study structure for the RCT will best suit your intervention? (2 points)
What intervention (or none) would be appropriate for the control group? (2 points)
Following this you would recruit, enrol and randomise your subjects into the trial. Randomisation is
essential to the design of a Randomised Controlled Trial (RCT). The bias of a trial is reduced considerably
by allocating subjects to the various intervention groups by a specified random method. It should be
done after enrolment so that both participant and trial manager cannot influence which group the
participant is allocated to.
Q4. ANSWER (4 points)

Session 2: TP4 2015
Page 23
Ethics
Blinding
Q5. How would you blind the

study?

study?

study?
Q6. Write a brief ethical

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

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

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

Session 2: TP4 2015
Page 24
Compliance
Quality control
A Group exercise (Tai chi)
B Home intervention team
C Home-based exercise
Quality control
To assess that the exercise
program is being carried out
properly and in the most
effective manner you could
record the level of attendance at
3 x weekly classes; provide a 6
monthly visit by an exercise
therapist or community nurse to
record participant involvement
and satisfaction etc.
Can you think of any others?
Quality control
Probably best done by having a
risk assessment of the home
and participant made before
and after the modifications.
Ideally this would be done by
two
separate
teams,
randomised to each visit one
half of the houses before
modifications, and the other
half after.
Compliance
Compliance could be a major
issue because it is a long-term
study and the exercise regimen
demands the ongoing
commitment of the subjects.
The most generally useful
principle is intention to treat
which would include data from
all subjects in the treatment
group in the analysis irrespective
of their adherence to the
exercise regimen. This controls
for the fact that any subsequent
real-world compliance with
the regimen will face similar
hurdles.
Another approach is to closely
monitor compliance and only
analyse data for the treatment
group from those who meet
certain pre-determined criteria.
This tests the efficacy of the
intervention, but in an artificial
manner.
Compliance
Compliance would not seem to
be a major issue here. However
de-cluttering the house and
remove trip objects from the
floor are things that may not be
complied with.
Similarly, participants may not
get into the habit of sensible /
frequent use of technical and
mobility aids, despite having
received direct advice from the
physiotherapist.
A random visit at some time
during the study to note the
actual state of the dwelling and
compliance with use of aids and
also to perform a risk
assessment might yield data to
correlate with frequency of
falls.
Quality control
To assess that the exercise regime
is being carried out properly and in
the most effective manner you
could arrange initial visits by the
physiotherapist to ensure that the
regime is followed currently and
then providing a calendar for
participants to record the days
when they exercise. Also, a 6monthly
visit
by
the
physiotherapist or a community
nurse.
Compliance
Compliance could be a significant
issue for this intervention and
study design as participants are
mostly expected to carry out this
exercise regime at home alone and
keep on doing it for long term.
Having the physiotherapist visit
and initiate the exercise in the
early months would help but is
costly and unlikely to be feasible if
rolled out as a large community
program.
Some intervention participants will
drop out causing issues with the
final analysis. In this case you could
use the principle of intention to
treat and include data from all
subjects in the treatment group in
the analysis irrespective of their
adherence to the exercise regimen.
This controls for the fact that any
subsequent real-world
compliance with the regimen will
face similar hurdles.
Another approach is to closely
monitor compliance and only
analyse data for the treatment
group from those who meet
certain pre-determined criteria.
This tests the efficacy of the
intervention, but in an artificial
manner.

Session 2: TP4 2015
Page 25
BLOCK 3
Choose intervention: Q7 choices
Q7. Choose which of the following 3 interventions seems the best choice, using the information that
you have available (e.g. sample size, length of study and your common sense). We estimate that you
would require 250 subjects in each group (intervention & control) to reduce the chance of a Type II error
to below 20%. Assume the 10-year absolute hip fracture risk for 80-year-old women is 10%. Follow-up
should be for 1 year at least. You reckon on acquiring ~$500,000 government funding. (Points 4/2/1)
1. $3600 per intervention and 1. $4500 per intervention subject 1. $1800 per intervention
control subject over 1 year.
and $600 per control subject over
subject over 1 year and
Drive subjects to exercise
2
years.
Necessary
home
$200 per control subject.
classes three times per week
modifications basic modifications
Initial and final risks
assessment by nurse. 4
($10 for class, $15 for bus. 48
paid for (e.g. rails, ramps),
extensive ones facilitated via
initial
visits
by
weeks of classes per year).
Intervention subjects have
government system/ family money
physiotherapist in first 2
Tai chi exercise class.
months and then 6(e.g. replace /improve shower
Controls are taught lowmonthly visits.
/baths etc). Three home visits by 2
intensity classes (stretching
Controls get 6-monthly
HIT
team
members
for:
exercises, relaxation etc).
assessment, giving careful advice
social visit by research
Initial
and
final
risks
on using technical and mobility
nurse.
assessment by research
aids, and also for maintenance and
nurse.
tidying of the home.
TOTAL STUDY COST:
Controls get usual care (GP) plus 3
TOTAL STUDY COST:
research nurse social visits.
TOTAL STUDY COST:
2. $1440 per intervention and
control subject for 1 year (48
weeks of classes per year).
Offer 3 free weekly Tai chi
exercise class to each
intervention subject. ($10
cost for class).
Controls offered free lowintensity exercise classes
three times a week. ($10 cost
per class). Initial and final
risks assessment by nurse.
TOTAL STUDY COST:
3. $350 per intervention and
control subject over 1 year.
Two free starter exercise
classes (Tai chi = intervention
group, stretching exercises =
control group), with take
home video of the exercise
regime, and 6-monthly home
visits by exercise therapist
($20 for the 2 starter classes,
$30 for video, $300 for
visits). Initial and final risks
assessment by nurse.
TOTAL STUDY COST:

Session 2: TP4 2015
Page 26
2.
$2800 per intervention subject

over 1 year. Necessary home
modifications
basic
modifications paid for, extensive
modifications facilitated via
government system/ family
money, e.g. rails, ramps, replace
shower/baths. Initial home
assessment visit with advice on
technical and mobility aids. 6and
monthly
follow-up
assessment and advice visits.
Controls get usual care (GP).
TOTAL STUDY COST:
3. $800 per intervention subject over
1 year.
Basic modifications only and oneoff home visit for assessment only
(no advice to participants on use
of technical or mobility aids).
Modifications include removing
rugs, grip tape on stairs, replacing
light bulbs in hallways and
stairwells with higher wattage
long life bulbs etc.
Controls get usual care (GP).
2. $1200 per treatment-group

subject over 1 year. Initial
and final risk assessment
by nurse. One initial visit
by physiotherapist and
then two 6-monthly visits
for
assessment
and
compliance.
Controls get usual care
(no visits).
TOTAL STUDY COST:
TOTAL STUDY COST:
TOTAL STUDY COST:

3. $500 per treatment-group
subject over 1 year. Initial
and final risk assessment
by nurse. One initial visit
by physiotherapist to teach
the tailored exercise
regime. No further visits.
Controls get usual care.
RECORD YOUR CHOICE

and reasons.
Dont forget to consider any
wider impacts that this
intervention might have:
RECORD YOUR CHOICE

and reasons:
Dont forget to consider any wider
impacts that this intervention might
have:
RECORD YOUR CHOICE

and reasons:
Dont forget to consider any
wider impacts that this
intervention might have:
Points awarded:
Points awarded:
Points awarded:

Session 2: TP4 2015
Page 27
Handling dropout
Confounders and bias
Q8. List possible important

confounders and considerations
for data analysis specific to the
intervention you have chosen
(1 point each, max. 4)


Q8. ANSWERS
Q8. ANSWERS
Q8. ANSWERS
Handling dropout
Handling dropout
Subjects may drop out of the

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

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

Session 2: TP4 2015
Page 28
Outcomes to measure
Outcomes to measure
The outcomes that should be measured here are pretty specific and relatively easy to measure. To clarify
which outcomes you would measure, consider your aims and research questions carefully. Start with the
main outcome measure(s), and then consider possible secondary outcomes.
Q9. Can you list them? (1 point for each outcome, max. 4)
Q9. ANSWERS:
1.
2.
3.
4.
Final thoughts
Quality of life measures are more important in some of these trials than others. For instance, with the
hip protector group, wearing the protector may be so uncomfortable that the patients quality of life goes
down considerably. On the other hand, they might feel liberated from worry about falling and become
more mobile and enjoy life more.
Will the study you have come up with answer your Q1. (the Clinical Question asked)?
***Total up the points for each Trial Design Group***

Who won?!

Session 2: TP4 2015
Page 29
3: Reflection and Discussion 10 mins

Which study of the three that you have designed do you believe would provide the most useful data for
improving quality of life for people at risk of osteoporotic fractures?
What aspects of the trial design process went well and why?
What aspects of the trial design process could have been done better?

Session 2: TP4 2015
Page 30
4. Finding out more about the impact of falls and prevention services (20 mins total):
Organise students into 4 groups for 10 mins activity and 5 mins whole discussion on what was learned:
1.
Group 1: Students browse through the Active and Healthy website:

http://www.activeandhealthy.nsw.gov.au/.
Take a look at the resources available.
What is the range of resources available?
Use the site to select appropriate fall prevention programs for patients listed below with different
needs and in a particular suburb or town in NSW.
Does/ should gender make a difference in your recommendations? What about cost and personal
funds/ health insurance cover?
Mobile 65 year old living in Leichhardt wanting to get more active

Post-fall 75 year old living in Artarmon with health insurance cover
Fragile 85 year old living in Paramatta with poor confidence
Active 75 year old with failing balance who is socially isolated
2.
Group 2: Students should browse the NSW Falls prevention network: http://fallsnetwork.neura.edu.au/.
Look at the resources and watch part of the video on:Case Studies on how to complete a falls risk
screening and management plan (We can choose a useful 5 min segment for them to view).
What range of assessment tools is available for health professionals?
Who are these suitable for?
How much do they cost and how easy would these be to implement?
What is there evidence-base?
Which have you met before?
3.
Group 3: Students would have watched the following videos of patient stories re falls and its
consequences:
shares her story following a fall at home. (You may have to fast forward parts of these to get through
this all but try to get the gist). https://www.youtube.com/watch?v=5GHymbyMeCo
What happened to these people? How could these falls have been prevented?
How did the emergency / health services respond?
What could have been done better? How did the health services assist them in their rehabilitation?
What were Suzannes and Colins major reflections on what had happened?
4.
Group 4: Students would have watched the parts of the CEC Falls Prevention Staying Active and Health
(Oct 2013): https://www.youtube.com/watch?v=s63fFex_zZQ
Students should try out the exercises and work out what each of the exercises is aiming to improve in
terms of muscle strength/ balance/ coordination/ which muscle groups are targeted, etc.
Would your grandparents be any good at doing these?
Do you think elderly people are likely to do these at home? Any suggestions?

Self directed homework exercise: to prepare for SGS5 look up information on the basic types of fractures and
how they usually occur. You can either use the references listed for SGS 5 on classification of fractures, or
alternately do your own search for this information.

Session 2: TP4 2015
Page 31
SGS 5: Fractures
Aims
This session aims to help students to understand the different types of fractures, why they occur, principles of
treatment and common complications resulting from different types of fractures.
Key Concepts
General principles of management of fracture

Immediate and delayed complications of fracture
Process
Activity
Approx Time
1.
Treatment modalities for fracture
60 mins
2.
Four cases of fracture
60 mins
3.
2 mins
1. Treatment modalities for fracture 60 mins

Using the reference provided, prepare to report back to the group on
the type of treatment,
the circumstances in which it is used and
the potential complications arising from treatment
Group 1: Closed reduction
Group 2: Open reduction
Group 3: Immobilisation - Sustained traction
Group 4: Immobilisation internal & external fixation
References:
1. Adams, J.C. and Hamblen, D. (1999) Chapter 3 in Principles of fracture Treatment in Outline of Fractures
th
including joint injuries. (11 ed.,. pp 28-51.) Edinburgh, Churchill Livingstone.
2. Boudrieau, R.J., and Sinibaldi, K.R. (1992) Principles of long bone fracture management. Semin Vet Med
Surg. 7(1):44-62.
http://searchfirst.library.unsw.edu.au/primo_library/libweb/action/dlSearch.do?institution=61UNSW_INST&vid=UNS
WS&search_scope=SearchFirst&tab=default_tab&query=any,contains,UNSW_DigiTool_ALMA97937
2. Four cases of fracture 60 mins

Suggested time: 10 minutes for preparation, 5 minutes for reporting back to the large group
Task:
For groups 1-2 and group 4:
Study the history and radiographs provided, with the help of the recommended references, prepare to report
on the following issues:
1. Which bone is fractured?
2. How old do you think the patient is?
3. Are the fragments displaced, and if so why are they so displaced?
4. How do you think the fracture happened?
5. What methods of treatment would be appropriate?
6. What complications might you expect to occur?
Group 1 Reference:
th
Adams, J.C. and Hamblen, D. (1999) Elbow and Forearm In Outline of Fractures including joint injuries. (11 ed.,
Chapter 11. pp 164-176.) Edinburgh, Churchill Livingstone.
Group 2 Reference:
Adams, J.C. and Hamblen, D. (1999) Special Features of Fractures in Children in Outline of Fractures including
th
joint injuries. (11 ed., Chapter 5. pp 74-78 and 159-163) Edinburgh, Churchill Livingstone.
Session 2: TP4 2015
Page 32
Group 4 Reference:
th
Adams, J.C. and Hamblen, D. (1999) Leg and Ankle in Outline of Fractures including joint injuries. (11 ed.,
Chapter 15. pp 252-260) Edinburgh, Churchill Livingstone.
For group 3:
Study the history and radiographs provided, with the help of the recommended references, prepare to report
on the following issues:
1. Which bone(s) are involved?
2. Describe the pathological changes in the affected bones
3. How old do you think the patient is?
4. How susceptible are the affected bones to fracture? Why? What type of fracture is this condition likely
to cause?
5. What methods of treatment would be appropriate?
6. What complications might you expect to occur?
Group 3 Reference:
th
Adams, J.C. and Hamblen, D. (1999) Spine and Thorax in Outline of Fractures including joint injuries. (11 ed.,
Chapter 8. pp 99-106) Edinburgh, Churchill Livingstone.
Students Note:
Students should be aware that the classification systems used in this SGS are not the only ones available and
that orthopaedic specialists differ in opinion on which is the best system. You are strongly recommended to
read, in your own time, the following references that address these issues.
When reading these papers keep the following questions in mind:
What is the purpose of classification of fractures?
Are the current classification methods appropriate? Sufficient?
Are there any other types of classifications?
References
1. Muller, M.E., Nazarian, S., Koch, P. & Schatzker, J. (1990) The comprehensive classification of fractures of
long bones. Berlin, Springer-Verlag.
2. Bernstein, M.S., Monaghan, B.A., Silber, J.S. & Delong, W.G. (1997) Taxonomy and treatment-a
classification of fracture classifications. J Bone Joint Surg., 79: 706-709.
http://www.bjj.boneandjoint.org.uk/content/79-B/5/706
2. Cases of fracture:
Case 1:
A woman fell onto her outstretched hand and injured her right wrist. Physical examination showed typical
dinner fork deformity with extremely tender wrist and crepitations.

Session 2: TP4 2015
Page 33
Case 2:
A male patient fell from horse back onto his left forearm. On examination his forearm was tender,
swollen and dorsally angulated to approximately 30.
Case 3:
A male patient with previous history of prostate carcinoma arrived to the hospital with persistent lower
back pain, weight loss and paraesthesia of the left leg. On examination he was pale, anorexic and had a
tender lower back at the level of the lumbar vertebrae. No palpable mass was detected on his back.

Session 2: TP4 2015
Page 34
Case 4:
A female motorcyclist arrived to the emergency department with multiple injuries 15 min after a collision
with a truck. On examination patient was conscious and alert but had multiple lacerations to the hands and
face as well as a large open wound on her right sheen with bone fragment protruding through the skin. Her
blood pressure was 90/50 and her heart rate was 110/min.

Presentations of alternative arthritis treatments
Students are to pre-read and prepare a short (3-5 slide) PowerPoint presentation to summarise evidence
associated with the alternative therapy and come to a clear conclusion as to the associated benefits and risks.
Students are encouraged to seek further information on these topics.
Group 1: Hyaluronan (also hyaluronic acid)
Rutjes, A.W.S., et al., (2012) Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and
Meta-analysis. Ann. Intern. Med. 157(3): 180-191. DOI:10.7326/0003-4819-157-3-201208070-00473.
http://www.ncbi.nlm.nih.gov/pubmed/22868835
http://annals.org/article.aspx?articleid=1305531
Group 2: Transcutaneous electrical nerve stimulation (TENS)
Vance, C.G. et al., (2012 ) Effects of transcutaneous electrical nerve stimulation on pain, pain
sensitivity, and function in people with knee osteoarthritis: A randomized controlled trial. Phys. Ther. 92(7):
898-910. DOI: 10.2522/ptj.20110183
http://ptjournal.apta.org/content/92/7/898.long
Group 3: Glucosamine
Wu, D. et al., (2012) Efficacies of different preparations of glucosamine for the treatment of osteoarthritis: a
meta-analysis of randomised, double-blind, placebo-controlled trials
Int. J. Clin. Pract. 67(6): 585594. DOI: 10.1111/ijcp.12115
http://onlinelibrary.wiley.com/doi/10.1111/ijcp.12115/abstract;jsessionid=22FB0C9A0F2DAC304825D
7F3B105E5A6.d02t03
Definitions:
http://clinicaltrials.gov/ct2/about-studies/glossary
http://web.med.unsw.edu.au/QMP/Glossary/Glossary.htm
Group 4: Magnetic and copper bracelets
Richmond, S.J. et al. (2009). Therapeutic effects of magnetic and copper bracelets in osteoarthritis: A
randomised placebo-controlled crossover trial. Comp. Ther. Med. 17(5-6):249-256.
http://www.sciencedirect.com/science/article/pii/S0965229909000569
Session 2: TP4 2015
Page 35
Scenario 2: Annie Simpson Arthritis

Schedule
Learning Activity
Principal Teacher
Scenario Plenary 2: Arthritis: Annie Simpson
Sean O'Neill
Lecture 20: Arthritis 1: Rheumatoid Arthritis
Sean O'Neill
Science Practical 6: Skeletal muscle physiology practical
Stephen Chan
Lecture 21: Arthritis 2: Degenerative Arthritis and Gout
Sean O'Neill
Lecture 22: Bones of the Lower Limb
Nalini Pather
Tutorial 2: Ethics Tutorial 1
Adrienne Torda
Science Practical 7: QMP: Weighing the Evidence
Barbara-Ann Adelstein
Scenario Group Session 6: Arthritis treatments

Hospital Clinical Skills Session 2: Assessing function in an interview & examining
the knee
Lecture 23: Management of Arthritis & Pain 1: Eicosanoids
Nicole Jones
Silas Taylor
Lecture 24: Management of Arthritis & Pain 2: Inflammatory Condition
Ric Day
Lecture 25: Hip joint and associated structures
Nalini Pather
Lecture 26: Management of Arthritis & Pain 3: Chronic Pain
Ric Day
Science Practical 8: Hip and thigh anatomy
Nalini Pather
Scenario Group Session 7: Upper Limb Cases
Nalini Pather
Lecture 27: Knee joint and associated structures
Nalini Pather
Lecture 28: Coping with chronic pain
Ute Vollmer-Conna
Ric Day
Overview
The scenario begins by sitting-in on a rheumatology meeting considering two cases, one of osteoarthritis and
one of rheumatoid arthritis. A number of health care practitioners are present at the meeting: rheumatologists,
physiotherapists, occupational therapists, and junior doctors. The cases are discussed and recommendations
and referrals made. In addition, two patients are present at the plenary that discuss their experience with
having rheumatoid arthritis and osteoarthritis.
To support student learning in relation to arthritis and related issues in the elderly. Students completing the
work associated with this scenario should be able to:
1. Describe the structure and function of the bones, muscles, vessels and nerves of the lower limb.
2. Describe the structure and function of synovial joints, using the hip, knee and ankle joints as examples.
3. Compare and contrast the causes, consequences and likely outcomes of degenerative joint disease
(osteoarthritis) and rheumatoid arthritis.
4. Describe the pathways of pain transmission from the peripheral to the central nervous system, and the
mechanisms by which analgesics and adjunctive treatments ameliorate pain.
Further details on each activity, including detailed capability references, suggested readings and websites, and
information on relevant disciplines, are contained in the eMed Map at http://emed.med.unsw.edu.au .

Session 2: TP4 2015
Page 36
SGS 6: Arthritis treatments

Aims
To review the physiology covered in this scenario

To review the scenario plenary and the learning issues
To evaluate alternative arthritis treatments
Key concepts
Scientific method
Evidence-based medicine
Practical approaches to disability
Activity
Approx Time
1.
Explore the scenario plenary and identify key issues
15 mins
2.
List learning goals and preview learning activities related to this scenario
5 mins
3.
Discussion and presentation of "alternative" arthritis treatments
50 mins
4.
Physiology quiz
30 mins
5.
Resources for SGS 7
2 mins
6.
Allocated time for peer teaching for group undertaking teamwork project
20 mins
1. Explore the scenario plenary and identify key issues 15 mins

2. List learning goals and preview learning activities related to this scenario 5 mins
From the previous discussion, the group should list what they consider the interesting and/or key issues of this
scenario. Students should then work through the scheduled learning activities in relation to these issues.
3. Discussion and presentation of alternative arthritis treatments 50 mins
A. Class discussion of alternative arthritis treatments (15 mins):
As a class, discuss how alternative medicine fits in with mainstream medicine. What are the benefits and
drawbacks of having alternative options available? What are the broader issues relating to a role of alternative
(integrative) therapies in treating patients?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Why do patients seek alternative treatments?

Why particularly for arthritis?
If an alternative therapy does no harm, should it be permitted?
Would you encourage you patient to seek a 'harmless' alternative therapy?
Should 'harm' be defined to include wasted patient time, energy and money?
What are the roles of the pharmacist in supporting the sales of these alternative therapies?
If you were to conduct research, what barriers do you foresee in terms of finding funding?
If your research were conducted, how would you disseminate that knowledge to patients and GPs?
Do alternative therapies have a potentially beneficial placebo effect?
Is the placebo effect worth more than debunking them?
Does the doctor have a role to help with an integrated therapy package?
What happens to patient trust if the doctor refuses?
B. Group presentations on arthritis treatments (25 mins):

Each group must present a 5 minute PowerPoint presentation using 3-5 slides, as outlined in SGS 5. The goal is
to summarise the evidence associated with the assigned alternative therapy and come to a clear conclusion as
to the associated benefits and risks.
Pre work information available in SGS 5 in the guide and in Moodle.
Moodle
Session 2: TP4 2015
Page 37
Scenario 2: Annie Simpson Arthritis
Process
C. Evaluation (10 mins):

Each group in turn should now critique the quality of the studies that they summarised. In the course of
evaluating the therapy, students should identify claims made about the mechanism of action and assess
whether these claims are reasonable in the light of their knowledge of physiology, pharmacology, and of the
disease process of arthritis. Discuss each of the following issues:
Which joints has the therapy been effective/approved for?
Is the therapy effective as an injectable, ingestible or topical?
What are the proper measures to determine if the therapy has reduced arthritis?
What is the best study design for the therapy?
4. Physiology Quiz 30 mins
5. Resources for SGS 7 2 mins
Students must bring their anatomy lecture and practical notes and/or anatomy text to the next session, which
will involve some neurological cases related to the upper limb.
6. Allocated time for peer-teaching for groups undertaking teamwork project 20 mins

Session 2: TP4 2015
Page 38
SGS 7: Upper Limb Cases

Aims
To consider the clinical applications of normal upper limb anatomy.

Compare and contrast the joint abnormalities caused by rheumatoid arthritis and osteoarthritis, as well as
their clinical manifestations.
Key concepts
Segmental innervation of the upper limb.

Likely sites and consequences of nerve lesions in the upper limb.
Applied anatomy of the shoulder
Differences between osteoarthritis and rheumatoid arthritis.
Process
Activity
Approx Time
1.
Cases affecting the upper limb
70 mins
2.
Rheumatoid arthritis and osteoarthritis comparison activity
40 mins
1. Cases affecting the upper limb 70 mins

Each group will present their answers/explanations to the whole class. PowerPoint slides containing feedback
on the cases will be provided, but students should be encouraged to try to answer the questions before this is
shown. You should allow approximately 15 minutes per case (or else you will run out of time!).
Case 1:
A 52 year-old woman presented with a history of left hand numbness and weakness, which has progressed
over a 2 year period. She also had developed weakness of the hand and had difficulty carrying heavy objects.
She noted that her symptoms were worsened by repetitive physical tasks such as cleaning or lifting heavy
objects. The numbness was most apparent over the medial aspect of the forearm and over the fifth digit. On
examination, there was atrophy of the thenar eminence and she had difficulty with thumb abduction and
flexion, as well as weakness of index finger adduction and abduction. Sensory examination revealed reduction
in sensation over the medial forearm and fifth digit. Deep tendon reflexes were normal.
1.
What muscle groups must have been affected to cause the motor deficits?
2.
What upper limb nerves supply these muscles?
3.
What spinal segments supply these muscle groups?
4.
What upper limb nerves supply the skin of the medial side of the forearm and hand?

Session 2: TP4 2015
Page 39
5.
What spinal segments supply the medial side of the upper limb and hand?
6.
What would you expect to see in a patient who has a lesion of the ulna nerve in the axilla?
7.
Based on this knowledge of motor and sensory supply of the hand, do you think the lesion is
more likely to involve spinal nerves (if so, which ones?) or a terminal branch of the brachial
plexus (if so, which one)?
Why?
8.
What are the possible underlying lesions/deformities that might cause this clinical picture?

Session 2: TP4 2015
Page 40
Case 2:
A 50 year old man comes to see you complaining of pain in the left shoulder and over the deltoid muscle. He
can abduct his arm for the first 60 degrees but from there the pain stops him from continuing further. When
you bring his arm up to 120 degrees of abduction he can abduct actively beyond this point. X-rays of the left
shoulder show a calcification (arrow) just above the greater tuberosity.
(i)
What are the rotator cuff muscles and why are they important?
(ii)
Describe the movements of the scapula during full abduction of the shoulder.
(iii)
What muscles are involved in full abduction of the shoulder
Supraspinatus and deltoid, serratus anterior and trapezius
(iv)
What is the specific role of each of these muscles in shoulder abduction?

Session 2: TP4 2015
Page 41
(iv)
What is the subacromial bursa? What is its function?
(v)
In what structure is the calcification seen in the X-RAY likely to be located?
(vi)
Explain the anatomical basis of the pattern of this mans pain, which is occurring in the mid-range
of abduction?
Case 3:
A 40 year-old man presented with a history of right upper limb weakness. The weakness was noted after he
had fractured his right clavicle following a fall from a horse. He had also noticed numbness of his right shoulder
and arm. On examination, there was weakness of elbow extension, wrist extension, forearm supination and
shoulder abduction and the triceps jerk was absent. There was reduced sensation over the lateral aspect of the
shoulder and over the postero-lateral aspect of the forearm.
1.
What muscles or muscle groups are likely to have been affected to cause the motor deficits seen in
this patient?
2.
What upper limb nerves supply these muscle groups?
3.
How do you know that biceps brachii is not likely to be involved in this patient?
4.
What other deficits would you expect to see if biceps was involved?
5. What upper limb nerve supplies sensation to the skin of the

(i) lateral side of the shoulder?
(ii) Posterolateral surface of the arm?

Session 2: TP4 2015
Page 42
6.
Explain the circuitry of the triceps jerk. What type of reflex is this?
7.
What nerves do you deduce are affected in this patient?
8.
How is it possible that these two nerves could be affected by the same injury?
9.
What structure is most likely to have been affected in this patient?
2. Comparison of rheumatoid arthritis and osteoarthritis 40 mins

Osteoarthritis
Rheumatoid arthritis
Definition
Epidemiology (incidence, age
groups, gender)
Risk factors
Joints typically affected
Pathological changes in affected
joints
Characteristics of joint pain
(exacerbating and relieving
factors)
Typical features on examination
of affected joints
Characteristic X-ray appearances
of affected joints
Local (peri-articular) and systemic
complications
Principles of management

Session 2: TP4 2015
Page 43
Scenario 3: Andrew Theodopoulos Bowel Cancer

Schedule
Learning Activity
Scenario Plenary 3: Andrew Theodopolous: bowel cancer
Lecture 29: Cellular Biology of Neoplasia
Science Practical 9: Pathology of Neoplasia
Scenario Group Session 8: Biology of neoplasia
Lecture 30: Tissue biology of neoplasia
Lecture 31: Colorectal neoplasms
Tutorial 3: Neoplasia
Campus Clinical Skills Session 3: Musculoskeletal patient scenarios role play
or SP work
Lecture 32: Environmental carcinogenesis
Lecture 33: Colorectal anatomy and histology
Lecture 34: Iron uptake, metabolism and stores
Science Practical 10: Knee Joint and Associated anatomy
Scenario Group Session 9: Project presentations
Lecture 35: Molecular biology of cell growth and neoplasia 1
Lecture 36: Molecular biology of cell growth and neoplasia 2
Science Practical 11: Cancer and genetic markers
Lecture 37: Anatomy of the Ankle and Foot
Lecture 38: Clinical approach to anaemia
Tutorial 4: Ethics Tutorial 2
Science Practical 12: Histology and Neoplasms of the Colon
Scenario Group Session 10: The Colon
Hospital Clinical Skills Session 3: Musculoskeletal Screening Examination
Lecture 39: Ethics and palliative care
Lecture 40: Clinical management of cancer
Lecture 41: Antineoplastic agents
Lecture 42: Central nervous system pharmacology / opioids
Science Practical 13: Anatomy of the Foot and Ankle
Scenario Group Session 11: Cultural attitudes to death and dying
Lecture 43: Bowel Cancer: Principles of a surgical approach
Lecture 44: Post-operative infections
Science Practical 14: Pain and the action of NSAIDS
Science Practical 15: Iron, iron storage & iron metabolism
Lecture 45: Anatomy of Nerve root Lesions of the lower limb
Lecture 46: Palliative care
Science Practical 16: Patterns of anaemia
Scenario Group Session 12: Cancer death
Lecture 47: Practical cancer pain management
Lecture 48: Psychosomatic models of illness
Lecture 49: Drug Metabolism in Ageing
Lecture 50: Information Session on the Prac Exam
Scenario Group Session 13: Pain management and course wrap up
Session 2: TP4 2015
Page 44
Principal Teacher
Eva Segelov
Betty Kan
Gary Velan
Gary Velan
Betty Kan
Betty Kan
Gary Velan
Silas Taylor
Louise Lutze-Mann
Ken Ashwell
Graham Jones
Nalini Pather
Ken Ashwell
Louise Lutze-Mann
Louise Lutze-Mann
Louise Lutze-Mann
Elizabeth Tancred
Giselle Kidson-Gerber
Adrienne Torda
Gary Velan
Ken Ashwell
Silas Taylor
Linda Sheahan
Trang Pham
Weng Ng
Trudie Binder
Elizabeth Tancred
Adrienne Withall
Rohan Gett
Hazel Mitchell
Trudie Binder
Rebecca Le Bard
Nalini Pather
Michael Barbato
Gary Velan
Jan Maree Davis
Frank Brennan
Ute Vollmer-Conna
Margaret Morris
Ken Ashwell
Nicole Jones
Learning Activity
Lecture 51: Formative Feedback Session
Lecture 52: Grief and bereavement
Principal Teacher
Gary Velan
Angela Heathwood
Initial scenario: Andrew Theodopoulos is a 75 year old, non-English speaking (NES), Greek widower who lives
with his son and family. He has become increasingly fatigued. The son was concerned but his father kept
denying symptoms, until one day he became quite unwell. At the GPs office: he admitted to some rectal
bleeding and pain, as well as increasing constipation. On examination, the abdomen was normal but on rectal
exam, a large mass was palpable and there was blood on the glove.
The GP sends him to a surgeon who performed proctoscopy and biopsied an obvious mass. Pathology showed
moderately differentiated adenocarcinoma and staging CT scan showed small liver metastases. His CEA was
elevated but LFTs were normal. Results were given to the son, who had been translating for the father. The
son asks that the diagnosis not be given to the father. After a lot of explanation, the family agree that the team
can discuss the condition with Andrew, because treatment is needed to prevent complete obstruction. The
prognosis is discussed with the patient and family using an interpreter. The patient is referred to an oncologist
and expresses a desire for aggressive treatment so he can return to visit family in Greece. Chemoradiation is
commenced, with the aim of down-staging the tumour to relieve the obstruction. The palliative care team is
introduced, to help with symptoms and also organise community follow-up.
Development scenario: Andrew copes well with the treatment and in feels better. The primary cancer improves
significantly as do the metastatic lesions. He has a low anterior resection with a temporary colostomy, followed
by further chemotherapy. He stops this whilst he returns to Greece for 4 months to visit family. He is well for
most of this until the last few weeks when he starts to lose weight and become fatigued. On return to Sydney,
he sees the oncologist who finds that the liver disease is now worse. Further chemotherapy is discussed but he
decides against active treatment. He renews his contact with the Palliative Care team who visit him at home
and provide services. He deteriorates rapidly and is admitted to the hospice when his son cannot cope with
caring for him at home. He dies one week later.
To support student learning in relation to pain, bowel cancer, death, dying and palliative care. Students
completing the work associated with this scenario should be able to:
1.
2.
3.
4.
5.
Describe the gross and microscopic anatomy of the colon, rectum and anus.
Explain the molecular pathogenesis and biological effects of neoplasms with particular emphasis on
carcinoma of the colon.
Describe the principles underlying the use of surgery and antineoplastic drugs (chemotherapy) in the
management of malignant neoplasms.
Discuss the role of palliative care and opioid analgesics in the management of advanced cancer.
Evaluate the social and ethical issues surrounding death from cancer, including the issues faced by health
professionals, patients, family and carers.

Session 2: TP4 2015
Page 45
Scenario 3: Andrew Theodopolous Bowel Cancer
Overview
SGS 8: Biology of Neoplasia

Aims
Explore the scenario and the related learning issues.

Discuss the biology of neoplasia and its clinical manifestations, as well as the impact of a diagnosis of
cancer.
Key concepts
Definition and nomenclature of neoplasia.

Differences between benign and malignant neoplasms.
Process
Activity
Approx Time
1.
Explore the scenario plenary and identify key issues
10 mins
2.
List learning goals
5 mins
3.
Preview learning activities
5 mins
4.
The biology of neoplasia
45 mins
5.
The impact of neoplasia
30 mins
6.
Project presentations preparation for SGS 9
5 mins
7.
Allocated peer-teaching time for teamwork project groups
20 mins
1. Explore the scenario plenary and video and identify key issues 10 mins
Students are to attend the Plenary to participate in the activities in this session.
2. List learning goals 5 mins
3. Preview learning activities related to this scenario 5 mins
4. The biology of neoplasia 45 mins
Students will work through a case study.
5. The impact of neoplasia 30 mins
Students should reflect on their personal experiences and attitudes towards cancer, in order to answer the
following questions:
How might personal and family experiences, as well as cultural and societal attitudes, shape
individuals responses to a diagnosis of malignancy?
What fears or expectations might a person experience when they are informed of a diagnosis of
malignancy?
How would these issues influence your approach if required to inform a patient about a diagnosis
of malignancy?

Session 2: TP4 2015
Page 46
6. Projects presentations preparation for SGS 9 5 mins

In the next SG session, students have time set aside for presentations of project for peer feedback before they
are submitted for assessment. It is expected that all project groups will report.
7. Allocated time for peer-teaching for groups undertaking teamwork project 20 mins

Session 2: TP4 2015
Page 47
SGS 9: Project presentations

Aims
To report on findings by groups investigating material for the projects
Key concepts
Living with chronic disease

Aged care assistance and facilities
Process
Activity
Approx Time
1.
Establish an order and a time limit for presentations
5 mins
2.
Project presentations and discussion
110 mins
3.
5 mins
1. Establish an order and a time limit for presentations 5 mins

All project presentations will select a timeslot.
2. Presentations and discussion ~110 mins
Generic criteria for giving feedback on oral presentations (see form on the next page)
Students are to watch the video of normal anatomy of the colon, rectum and anus and answer the quiz prior to
the next session. Links are available in Moodle to the video and questions.
Students will be in groups of two and will need to bring a computer per group to complete activities in the next
session.

Session 2: TP4 2015
Page 48
Feedback form: Assessment of the group project presentation

Project title:
Scenario Group:
Project Group members:
Date:
Criteria
Time:
Grade
(P-, P, P+)
Comments
EXPLANATION OF PROJECT
Project aim, methods and findings were clearly
explained;
Findings are based on the evidence available;
Methodology is appropriate and adequate for the task.
PRESENTATION
Oral presentation was clear, well structured and easily
understood;
Presentation demonstrated consistency in style e.g.
PowerPoint slides;
Timing was controlled so that most aspects were
covered;
Audio visual aids or handouts were clear, well
structured and easy to read.
UNDERSTANDING
Project team appeared to have a good understanding of
the topic;
Project has an introduction and conclusion;
Able to answer audience questions.
STIMULATING LEARNING
Presentation was interesting;
Significant issues and unanswered questions were
highlighted;
I learned a lot from this presentation;
This presentation stimulated me to find out more about
the topic.
TEAMWORK
The transition from one speaker to the other went
smoothly;
Team members demonstrated support for the speaker
i.e. not talking amongst themselves when a group
member was presenting;
Presenters have minimal overlap in their presentations;
The group engaged the audience and demonstrated
team unity.
Did the group meet the assessment criteria for the group project adequately (i.e. a Pass level)? Yes / No
Please add specific comments (more space overleaf):
P- represents a relatively poor and/or incomplete performance, in terms of the assessment criteria
P represents a performance that achieves most of the stated criteria, in a reasonably effective manner
P+ means that all the criteria were attained, and that they were done in a way that demonstrated a clear understanding of and mastery of
the topic.
Full definitions at: http://medprogram.med.unsw.edu.au/med3802web.nsf/page/Grading+System

Session 2: TP4 2015
Page 49
SGS 10: Colorectal cancer screening and clinical anatomy of the colon, rectum
and anus
Aims:
Discuss means of screening for colorectal carcinoma

Explore the clinical anatomy of the colon, rectum and anus.
Discuss the possible causes of per rectal bleeding.
Discuss the possible approaches to surgical treatment of colorectal carcinoma.
Key concepts:
Screening for colorectal carcinoma

Topography of the large intestine.
Structure and anatomical relations of the rectum and anus.
Findings on a normal per rectal examination.
Differential diagnosis of per rectal bleeding.
Anatomical basis of the surgical treatment of carcinoma of the bowel.
Process:
Activity
Approx Time
1.
Screening for bowel cancer
20 mins
2.
Test your knowledge of colorectal anatomy: Jeopardy game
25 mins
3.
The case history
5 mins
4.
Questions on the case history for discussion
20 mins
5.
Further developments in the case
15 mins
6.
The disease progresses
15 mins
7.
Debrief
5 mins
8.
Preparation for SGS11
5 mins
Before attending the SG session.

Students have watched the video of the normal anatomy of the colon, rectum and anus 20 minutes
http://moodle.telt.unsw.edu.au/mod/book/view.php?id=653512&chapterid=87474
Have taken the SmartSparrow adaptive tutorial that tests your ability to identify features of the anus and
rectum 20 minutes
The video will demonstrate key aspects of the anatomy of the colon, rectum and anus. These include:
Parts of the colon
Abdominal organs in contact with the large intestine
Peritoneal attachments of the large intestine and their clinical significance
Structure of the wall of the large colon (taeniae coli, appendices epiploicae)
Arterial supply of the colon and rectum
Venous drainage of the large intestine
Features palpable on a normal digital rectal examination in both males and females
Internal features of the anus and rectum, haemorrhoidal venous plexuses, internal and external anal
sphincters
Changes in mucosa along the length of the normal anorectal canal
Carcinoma of the colon and rectum is the third most common malignancy in both men and women in western
countries and the lifetime risk of carcinoma of the large intestine for someone living in those countries is about
5%. Anal and perianal disorders are also very common in western countries, accounting for about 20% of
general surgical outpatient referrals. Disorders of the bowel and anus can be distressing and embarrassing.
Patients often tolerate symptoms for long periods of time before seeking medical help and/or make use of
over-the-counter pharmacy medication to relieve discomfort. Although many disorders of the anorectum (e.g.

Session 2: TP4 2015
Page 50
haemorrhoids, anal fissures) are less serious than bowel cancer, they affect quality of life significantly and it is
clearly important to distinguish between them and life-threatening carcinoma of the rectum or anus.
The causation of many disorders of the large intestine and anus is linked to diet. Daily intake of red or
processed meat has been shown to increase bowel cancer risk by 30%, whereas a twice-weekly intake of fish
reduces it by 30%. The typical low-fibre western diet results in a much slower whole-gut transit time and may
allow a more prolonged period of contact of carcinogens with the bowel wall. Anti-oxidants in fruit and
vegetable may also have a protective role. Low levels of fibre in the diet also contribute to hard faeces,
constipation and straining to pass motions, which contribute to the causation of haemorrhoids and anal
fissures.
Understanding the structure and function of the colon, rectum and anus is key to understanding the
pathophysiology and surgical management of conditions in this region.
Students will find the following Resources assist with the activities for SGS10
Burkitt, H.G., Quick, C.R.G., & Reed, J.B. (2007) Chapter 30 in Anal and perianal disorders. Essential Surgery.
th
Problems, Diagnosis and Management. (4 ed.) Churchill Livingstone Elsevier.
http://unsw.eblib.com/patron/FullRecord.aspx?p=1746696
IMPORTANT: Please bring an internet capable laptop to this SG session (at least one per pair of students).
You will need it to access Moodle and SmartSparrow.
1. Screening for colon cancer 20 mins
The following is a list of tests that can be used to screen for colon cancer. Which have been/are being used as
screening tests for the population? At what age would individuals normally be screened? Which tests are used
as diagnostic tools rather than screening? What is the basis of each of the following tests? i.e. what are they
examining? Note that two of the tests (which?) are still in clinical trials as screening tools.
Used for
screening
Test
Used for
diagnosis
Basis of test
FOBT
Colonoscopy
Sigmoidoscopy
Barium Enema
CT Colonography
Stool DNA
Mutation Tests
CT = computed tomography; FOBT = fecal occult blood test.
2. Test your knowledge of colorectal anatomy using the Jeopardy game 25 mins
This is a PowerPoint adaptation of the TV game show Jeopardy where contestants are given clues in the form
of an answer and then must provide their responses in the form of a question.

Session 2: TP4 2015
Page 51
3. Consider the case history and clinical examination 5 mins

Case history
A 68 year-old man comes to see you (his general practitioner) because he has noticed blood in and around his
motions when he passes faeces. This has become more noticeable over the last 2 months. He also says he
feels weak and is easily fatigued, but has not noticed any weight loss. He has had occasional episodes of feeling
as if the bowel has not emptied properly when he passes a motion. He has no family history of any bowel
disease.
Clinical examination
The mucosa of the patients oral cavity is pale, as are his nail beds. The abdominal examination reveals slight
distension due to gas, but no masses can be felt.
You conduct a rectal examination. There are some haemorrhoids visible emerging from the anus, but no
evidence of anal fissures, anal fistulae or sinuses in the perianal region.
The digital rectal examination and proctoscopy reveal a flat, hard, oval lesion with rolled edges and a central
depression situated on the anterior wall of the rectal ampulla. The lesion is approximately 5 cm in diameter
and blood is noted on the examining glove at the end of the digital examination.
4. Questions on the case history 20 mins
Still in your groups from activity 2, spend 10 minutes considering the following questions concerned with points
arising from the case history. You may use your internet access to help you answer the questions. When all
the groups have had time to consider the questions, your facilitator will work through the SG PowerPoint with
answers.
These questions are also listed in the online adaptive tutorial under Section B.
Question 1. What are some possible causes of bleeding per rectum?
Question 2. What is proctoscopy?

Session 2: TP4 2015
Page 52
Question 3. What are haemorrhoids? What causes them? What are the associated symptoms and signs?
Question 4. What is an anal fissure? Where are they found?
Question 5. What is a fistula-in-ano?
Question 6. What is the feeling of incomplete emptying of the rectum called?

Session 2: TP4 2015
Page 53
5. Further developments in the case 15 mins

The patient undergoes a wide surgical resection of the lesion in the rectum with clearance of the draining
lymph nodes. Care is taken during the surgery to avoid unnecessary palpation of the lesion. Blood vessels
draining the area of affected bowel are divided and ligated early in the surgical procedure. Histological
assessment shows that the resection margins of the rectum are free of tumour, but several of the draining
lymph nodes are positive for adenocarcinoma.
The anal sphincter was saved and a pelvic reservoir was created by making a J shaped loop (J-pouch technique).
The patient then completes a course of adjuvant radiotherapy and chemotherapy.
Students are to log into Moodle, and click on the Adaptive Tutorial under SGS 10 in the Learning Resources
area and answer the questions in Section C of the SmartSparrow: SGS10: Clinical Anatomy of Colon, Rectum
and Anus.
6. The disease progresses 15 mins
A few days after the operation the patient develops a fever and a peritoneal abscess is discovered and drained.
Fortunately, antibiotic therapy leads to recovery.
The patient develops enlargement of the liver, abdominal distension and dyspnoea (breathlessness) over the
subsequent 12 months. On examination at this time the patient has yellow skin (jaundice), and a distended
abdomen with an enlarged, hard, irregular liver. A moderate amount of ascites (free fluid in the abdominal
cavity) is apparent. Abdominal and chest MRI scans reveal metastases in the liver and lungs. The man
develops pneumonia 20 months after the initial presentation.
Students are to continue with Section D in the SmartSparrow Adaptive Tutorial: SGS10: Clinical Anatomy of
Colon, Rectum and Anus.
7. Debrief - 5 mins
Consider how this clinical case relates to other scenarios.
How might this outcome have been avoided?
What sort of screening could have prevented this outcome?
What sort of palliative care options might be available to our patient?
Students are to read the articles for the Cultural attitudes to death group exercise, available under SGS 11 and
Moodle. Students need to bring their electronic devices to complete the course evaluation at the next SGS.

Session 2: TP4 2015
Page 54
SGS 11: Cultural attitudes to death and dying

Aims
To reach an understanding of cultural differences in attitudes to death and dying

To deal sensitively and appropriately with end-of-life issues with patients and families from culturally and
linguistically diverse backgrounds
To be aware of common issues facing all cultural groups in the area of death and dying
To provide an opportunity for feedback to the course designers and to the facilitator
Key concepts
To understand cultural diversity to disclosure and truth-telling around the area of death and dying
To understand cultural differences in relation to grief and bereavement
Process
Activity
Approx Time
1.
Completing course and facilitator evaluations
15 mins
2.
Development of scenario
20 mins
3.
Cultural attitudes to death and dying video
20 mins
4.
Cultural attitudes to death and dying group exercise
20 mins
5.
Report back to group for activity 4 and discussion
35 mins
6.
5 mins
1. Completing course and facilitator evaluations 15 mins

We value your feedback on this course. The Ageing & Endings Convenor, Co-Convenor and Course DIG look at
your comments carefully in guiding the development of the course. Students are to complete course (Form A)
and facilitator (Form C) CATEI evaluation forms. Thank you!
Instructions for students:
1. Log into myUNSW (https://my.unsw.edu.au/ ) or Google myUNSW
2. Click on the CATEI icon (top left hand corner)
3. Select Evaluate Tutor / or Evaluate Course
4. Select Choose and select the correct SG Facilitator and SG time
5. Complete the evaluation form and submit.
TIP: For iPhone users, turn the phone to landscape to see the form more easily. Please ask your students to
complete the surveys using their smart phones, their laptops or the room PC, during this SGS.
2. Development of scenario 20 mins
3. Cultural attitudes to death and dying video 20 mins
4. Cultural attitudes to death and dying group exercise 20 mins
Group 1
Are there different attitudes regarding disclosure of serious/terminal illness to the patient?
Is death talked about or a taboo subject?
How might a persons religious or spiritual views affect their willingness to undergo both screening and
treatment for cancer?
Reflect on your own cultural perspectives in relation to these issues.

Session 2: TP4 2015
Page 55
Group 2
Do Australian doctors and hospital staff understand different cultural perspectives?
What do doctors need to know in order to better handle spiritual and religious views in end-of-life care?
How are families involved in decision-making? As death approaches, what are the most important things
for families to consider?
Reflect on your own cultural perspectives with reference to these issues.
Group 3
What are the cultural differences in attitudes towards euthanasia?
What are the attitudes regarding the meaning of pain and towards pain-relief in end-of-life care?
Are there differences between Australian-born and overseas-born members of the same cultural groups?
Reflect on your own cultural perspectives with reference to these issues.
References:
Firth, S. (2005). End-of-life: a Hindu view. The Lancet. 366(9486), 682-686
http://sfx.nun.unsw.edu.au:9003/sfx_local?issn=0099-5355&date=2005&volume=366&issue=9486&spage=682
Sachedina, A. (2005). End-of-life: the Islamic view. The Lancet. 366(9487), 774-779.
Dorff, E.N. (2005). End-of-life: Jewish perspectives. The Lancet. 366(9488), 862-865.
Keown, D. (2005). End-of-life: the Buddhist view. The Lancet. 366(9489), 952-955.
Engelhardt Jr, H.T. & Smith Iltis, A. (2005). End-of-life: the traditional Christian view. The Lancet. 366(9490),
1045-1049.
Markwell, H. (2005). End-of-life: a Catholic view. The Lancet. 366(9491), 1132-1135
Baggini, J. & Pym, M. (2005). End-of-life: the Humanist view. The Lancet. 366(9492), 1235-1237.
5. Report back 35 mins

Pain Management presentations
Further information and references for each group are listed in Moodle and in the Guide under SGS 13.
Group 1: Side effects of opioids including sedation
Group 2: Addiction, tolerance and dependence
Group 3: Morphine as the 'last resort'

Session 2: TP4 2015
Page 56
SGS 12: Cancer Death

Aims
To understand death as a natural part of life.

To understand the role of and the importance of carers in the dying process and the impact that this has
on them.
To understand the role of the palliative care services both in the hospital and community settings.
Key concepts
Death is inevitable and care of the dying requires the same degree of professional expertise as any other
area of medicine.
Care of dying patients by relatives, families and friends has both positive and negative aspects.
Role of palliative care services in meeting the needs and preferences of dying patients and their carers with
the prevention and relief of suffering.
Process
Activity
Approx Time
1.
Interviews with professionals in palliative care
30 mins
2.
End of Life Care: Herbie
50 mins
3.
Carer issues
25 mins
4.
Reminder Preparation for SGS 13
5 mins
1. Interviews with professionals in palliative care 30 mins

2. End of Life Care: Herbie 50 mins
3. Carer issues 25 mins
4. Reminder Preparation for SGS 13 5 mins
Pain Management presentations
Students must work in three groups to read the recommended reading for their allocated area. Each group is
to give a 5-10 minute presentation to the class covering the topics below. Further information and references
for each group are listed in Moodle and in the Guide under SGS 13.
Group 3: Morphine as the last resort

Session 2: TP4 2015
Page 57
SGS 13: Pain management and course wrap up

Aims
This session is in two main parts.
The first part of the session will look at pain management, building on the lecture on this topic. It aims to
support understanding of:
Cancer pain and its treatment

The use of opioids and the opioid myths
Barriers to good pain management:
Addiction issues
Tolerance/dependence issues
The myth of inevitable sedation
The myth that opioids should be kept until the last
What to use when the pain gets really bad
Fear of hastening death
The importance of good pain management advice to patient and carers
In the second part of this session students will wrap up the course.
The aim is to encourage students:
To resolve unanswered questions raised by the scenario and the course.
To support preparation for the course examination.
Key concepts
Options for the treatment of cancer pain

Barriers to good pain relief in cancer patients
Major myths surrounding opioid use in the cancer patient
Addressing any unresolved learning issues from scenario and course
Process
Activity
Approx. Time
1.
Cancer pain management
40 mins
2.
Pain management group exercise
55 mins
3.
Course wrap up
15 mins
1. Cancer pain management 40 mins

Students will view a cancer pain management video and discuss. Discussion to explore the issues. Students are
to refer back to lecture materials related to cancer treatments.
2. Pain management group exercise 55 mins
At the end of SGS 11 students were divided into three groups and required to read the recommended reading
for their allocated area. Each group is to give a 10 minute presentation to the class covering the topics below.
A recent review of the overall topic may also assist in the groups discussion (all groups to read).
Mercadante (2015) The use of opioids for treatment of cancer pain. Expert Opin. Pharmacother 16(3):389-394.
doi:10.1517/14656566.2015.989213.
http://informahealthcare.com/doi/pdf/10.1517/14656566.2015.989213
Q1. What are the expected side effects?
Q2. How would you manage those?
Q3. What strategies could be used to improve compliance?
Q4. How would you tell whether someone is taking their pain medications correctly?
Session 2: TP4 2015
Page 58
Group 1 Reference:
Woodruff, R. (2004) Barriers to good pain control. In Palliative Medicine: Evidence-based symptomatic and
th
supportive care for patients with advanced cancer. (4 ed., pp 82-84.) South Melbourne, Vic: Oxford University
Press. (available in Moodle)
Q1. Is addiction likely in patients with cancer pain?
Q2. How would you discuss issues of addiction, tolerance and dependence with a cancer patient who is
experiencing pain?
Q3. What other concerns or points would you need to make in such a situation?
Group 2 Reference:
Woodruff, R. (2004) Opioid Analgesics. In Palliative Medicine: Evidence-based symptomatic and supportive care
th
for patients with advanced cancer. (4 ed., Chapter 9. pp 96-110.) South Melbourne, Vic: Oxford University
Press. (available in Moodle)
Group 3: Morphine as the last resort
Q1. When should morphine be introduced in the cancer patient?
Q2. What would you anticipate would be the main concerns and fears patients and their families would
have about their use of morphine?
Q3. How would you explain such a situation to a relative who was worried about morphine hastening the
death?
Group 3 References:
World Health Organization (2015) Analgesic Ladder. http://www.who.int/cancer/palliative/painladder/en/
Woodruff, R. (2004) Patient Opiophobia. In Palliative Medicine: Evidence-based symptomatic and
th
supportive care for patients with advanced cancer. (4 ed., pp 107-108.) South Melbourne, Vic.: Oxford
University Press. (available in Moodle)
Dahl, J. and Portenoy, R. (2004) Myths about controlling pain. Journal of Pain and Palliative Care
Pharmacotherapy. 18(3),55-58.
http://er.library.unsw.edu.au/er/cgi-bin/eraccess.cgi?url=http://dx.doi.org/10.1080/J354v18n03_05
Group 4: Treatment of neuropathic pain
Q1. What is the definition of neuropathic pain and how is it distinguished from other types of pain?
Q2. What are the current available treatments for neuropathic pain?
Q3. What is the efficacy and side effects associated with these treatments?
Group 4 Reference:
Finnerup, N.B., et al (2015) Pharmacotherapy for neuropathic pain in adults: a systematic review and metaanalysis. The Lancet Neurology Volume 14(2), p162173. doi:10.1016/S1474-4422(14)70251-0
http://er.library.unsw.edu.au/er/cgibin/eraccess.cgi?url=http://www.sciencedirect.com/science/article/pii/S1474442214702510
Moodle
3. Course wrap up 15 mins
In 2016, Ageing & Endings B will focus on Menopause, Breast Cancer and Neurodegeneration.

Session 2: TP4 2015
Page 59
Assessment
Assessment overview
Assessment in this course involves an assignment, a group project, a course examination and attendance
requirements.
You must complete one group project from the set list, and one assignment. The assignment may be chosen
from the set list or negotiated on a topic of your choice which is relevant to the themes of the course.
You are reminded of the program requirements to negotiate at least one assignment, and to complete at least
one communication assignment, during Phase One.
Successful completion of the assignment and project work is necessary before your exam results will be
released.
You are reminded that questions relating to the practicals, tutorials and scenario group sessions may be
included in the end of course examination.
Refer to the Phase 1 guide and Medicine Program website for information on the format of the end of course
examination and for detailed progression rules.
A formative online assessment will also be available.
While your final result for the course will largely be determined by your performance in the end of course
examination, the assignment and project work is also an important component of the assessment for the
course. The graded assignments and projects will form part of the portfolio examination at the end of your
second year, where they will be used as evidence of your achievement in each of the capabilities.
Attendance
You are expected to attend all classes and it is to your advantage to do so.
The Faculty has set minimum attendance requirements for this course. You must:
attend all scenario group sessions. Students with approved absences need to attend at least 80% of
scenario group sessions AND
attend all hospital and campus clinical skills sessions and ethics tutorials sessions. Students with
approved absences need to attend at least 80% of hospital and campus clinical skills sessions and ethics
tutorials.
Facilitators / Tutors will keep attendance records in scenario group sessions, hospital clinical skill sessions,
campus clinical skills sessions, and ethics tutorials.
If you fail to comply with the above attendance requirements, the Faculty has the right to refuse to allow you
to sit the end-of-course examination. As a result, an Unsatisfactory Fail (UF) will be recorded as your result for
the course.
All applications for exemption from attendance at forthcoming classes of any kind must be made as outlined in
the Faculty policy on extra-curricular activities affecting attendance in MBBS Program.
(http://www.med.unsw.edu.au/medweb.nsf/resources/csp1/$file/Extra-curriculActivitiesPolicy.pdf).
In the case of illness or of absence for some other unavoidable cause, you may be excused by the Registrar for
non-attendance at classes for a period of not more than one month or, on the recommendation of the Dean,
for a longer period.
Where required, explanations of absences from classes should be delivered to the Medical Education and
Student Office and include medical certificates, where applicable. Medical certificates should NOT be given to
teaching staff.

Session 2: TP4 2015
Page 60
It is your responsibility to frequently check your official student email account and the Timetable for assigned
classes and any changes. Ignorance of classes, which are scheduled in the Timetable, is not an acceptable
excuse for non-attendance.
You can only attend classes to which you are allocated. You may not attend practicals or other classes at
different times to your timetable. Tutors may ask you to leave if you are not in your allocated class.
You are expected to be punctual in attendance at all classes.
Criteria for Grades for Assignments and Projects
Provided below and on the Medicine Program website: https://medprogram.med.unsw.edu.au/grading

Focus capabilities
Projects and assignments will focus on two or three of the eight capabilities. Specific assessment criteria will be
described for each focus capability.
Criteria for the generic capabilities for all project and assignment reports
The following criteria will be used for the assessment of the generic capabilities in assignment and project
reports. The four grades F P- P and P+ will be used to report results for these capabilities:
Criteria
Effective
communication:
(applicable to both
assignments and
projects)
Clarity (clear, simple, grammatical language, terms explained)

Logical structure.
Appropriate language, length, style and format for the intended audience
Appropriate use of media (visuals, graphs, video, etc.)
Sources (range, citation standards, quality, relevance, search strategy, people

consulted)
Scope (addresses all requirements of the assignment or project)
Critical thinking (evidence of awareness of bias in sources, others viewpoints,
own views, logical argument)
Self-directed
learning and
critical evaluation:
(applicable to both
assignments and
projects)
Development as a
reflective
practitioner:
(applicable to
assignments)
Teamwork:
(applicable
projects)
to
Negotiated assignments will be marked on the following additional criteria:

Quality of the learning plan, including the assessment criteria.
Time management, including reporting, drafts, deadlines
Search strategy
Provides a credible self-assessment of the quality of the assignment report in
terms of its strengths and weaknesses in meeting the assessment criteria for the
focus and generic capabilities.
Identifies strengths and weaknesses of the research process used and articulates
credible plans to improve research skills
Reflects on the assignment topic, the research process and draws implications for
wider learning and future practice.
Provides evidence of team meetings by appending to the project report
documents such as: agendas, minutes, summaries of discussions, or lists of
decisions made.
Provides evidence of the evaluation of the group process using tools provided,
focusing on at least one of the following: group roles and responsibilities,
communication between group members, resolution of conflicts, behaviour in
group meetings (task, support, non-productive).
Identifies teamwork issues, (e.g. discussion of the contributions of team members
as required) that facilitated or impeded the group process and outlines plans to
address these in future group work.

Session 2: TP4 2015
Page 61
Assessment
Capability
Assignments and projects offered in AEA 2015

Assignments
Title
Focus capability
Exempt Assignment
A1
Spinal Stenosis
Using Basic and Clinical Sciences

Patient Assessment and Management
A2
Neoplasia: Educating the Public - Quota of 25

students

Effective Communication
A3
Immunotherapy for the Treatment of

Genitourinary Cancers

A4
Euthanasia and Ethics
Understanding ethics and legal responsibility

Social and cultural aspects of health and disease
A5
To supplement or not? Weighing up Calcium

and Vitamin D supplementation in reducing
osteoporosis risk. (QMP assignment)

Self-directed Learning and Critical Evaluation
Projects
P1
P2
P3
P4
P5
Title
Focus capability
Arthroscopic Repair vs Total Knee

Replacement

Chemotherapy-Induced Peripheral
Neuropathy (CIPN)
Interview with palliative care patients:
Metastatic malignancy compared with endstage renal failure- Quota 5 groups
Interview with health professionals working
in palliative care Quota 10 groups

Teamwork
Development as a Reflective Practitioner
Integrating learning through developing

questions for an online tutorial
Self-Directed Learning and Critical Evaluation

Teamwork

Please note that project groups will be expected to report to their scenario group in scenario group session 9,
and that all members of the group will be expected to answer questions from the group and the facilitator on
the presentation.
Please use the Discussion area in Moodle for posting questions regarding assignments and projects. Enquiries
that relate specifically to the tasks of the particular assignment or project and related content, should be
directed to the appropriate thread in the Discussion areas located under Assessment Activities on Moodle.
Word Count
The word count for assignments and projects includes all the text in the report, apart from the cover page and
the reference list. Assignments are up to 2000 words and projects up to 2500 words, unless there is an explicit
exception for any individual assignment or project.
You should format your report in accordance with the specification on the Medicine program website, and
include a word count. Ensure that you carefully reference your written work using the UNSW Medicine APA
referencing style (http://web.med.unsw.edu.au/infoskills/apa/apa.html). Please refer to the Medicine program
website for penalties that will be applied to reports that exceed the maximum length:
http://medprogram.med.unsw.edu.au/assignments-and-projects-phase-1 (login required)

Session 2: TP4 2015
Page 62
Due dates for registering your choice of assignments and projects

th
Registration for assignments and projects with quotas
4pm Friday 18 September 2015
Submission of proposals for negotiated assignments
9am Monday 21 September 2015
Registration for all other assignments and projects
4pm Friday 25 September 2015
th
*NB: Only one student from your group project group should register in eMed on behalf of the group.
Once you have been named in a project group you will not be able to register for any other group projects.
Due dates for submission of project reports and assignments

th
Submission of Assignments
9am Monday 19 October 2015
Submission of Negotiated Assignments
9am Monday 26 October 2015
Submission of Project Reports and any supporting evidence
9am Monday 2 November 2015
th
nd
You may submit earlier if this suits your study schedule.
Negotiated assignments
Proposals for a negotiated assignment must be submitted by 9 am Monday 21 September, 2015 (Monday of
week 2) to the eMed Registrations system. Do not proceed with your proposed assignment until you get
approval from the negotiated assignment group (NAG). Please note that first year students should not
negotiate an assignment until at least the last course of their first year. See the program website for
information on the process for negotiating an assignment at:
https://medprogram.med.unsw.edu.au/negotiating-assignment and watch the videos on Negotiating
assignments in the Assessment Information and Activities on Moodle.
Submission to eMed Portfolio

Information on submitting assessments to eMed is available at:
http://medprogram.med.unsw.edu.au/assignments-and-projects-phase-1#tab-303400340
Students submitting a website should submit a zip file to eMed; but if the website is too large (over 10Mb)
then you should submit a dummy file on eMed and hand in a CD that is clearly labelled with your student
number and the receipt number of your project to the Medical Education and Student Office. The dummy file
should be a single page word document specifying your name, student number and project title and state that
a CD has been submitted to the Medical Education and Student Office. Please note that if you submit the
website on CD, it will be destroyed after marking and will not be available for your Portfolio.
Please refer to the Medicine Program website for penalties that you will incur if you submit after the due dates.
(http://medprogram.med.unsw.edu.au/penalties)
If there are extenuating circumstances that prevent you from meeting the due date for submission, contact the
course convenor before the due date to request an extension. In most cases a medical certificate or a similar
level of documentation will be required.
SOCA Assessments
Refer to the 2015 Phase 1 CCS Guide for details of the SOCA requirements
th
Midnight on Sunday 13
Submission deadline for SOCA Forms
September 2015

Session 2: TP4 2015
Page 63
Academic honesty and plagiarism

Students should be familiar with the UNSW Student Conduct Policy and the policies relating to code of conduct
particularly relating to academic misconduct and plagiarism https://student.unsw.edu.au/conduct
The Faculty of Medicine regards the maintenance of academic integrity by staff and students as a matter of the
highest priority. The Faculty participates in the Universitys use of the similarity detection software Turnitin
(see http://www.turnitin.com). Students work submitted to the eMed Portfolio system will be compared to
other items in the eMed system, to material on the Internet, electronic publications and to items in the Turnitin
database.
You can check your own assignment and project against Turnitin before you submit it to eMed Portfolio by
using the link in the Moodle module for this course located under Assessment Information and Activities.
The Learning Centre website is main repository for resources for staff and students on plagiarism and academic
honesty. These resources are located at: https://student.unsw.edu.au/plagiarism
Exempted Assignment
As with all quota assignments, registration must occur by 4 pm, Friday 18 September 2015 (Friday week 1).
Students in their second year of the program may apply for an assignment exemption. Students in first year
are not eligible for assignment exemptions. Second year students may apply as often as they like, but may only
take one assignment exemption in the phase.
Please note that to qualify to sit the portfolio examination at the end of second year students must have
passed 12 assignments and projects in total, including at least 6 assignments (from 7 courses). When
considering if you will apply for an exempt assignment, you should keep this in mind. If you exempt from an
assignment early in the second year, and then fail another assignment you will not be able to meet this
requirement.
Students will also need to have evidence from assignments in all capabilities, except perhaps Teamwork - it is
accepted that assignment evidence for the Teamwork capability is hard to get in Phase 1. Therefore, before
applying for an assignment exemption, students should ensure that the evidence in their portfolio is
demonstrating consistent or improving achievement in the capabilities, and that they are confident that their
portfolio will contain positive evidence addressing all capabilities when submitted. In order to be eligible to
submit your Portfolio you must have overall grades of P-, P or P+ in at least 12 assignments and projects,
including at least 6 assignments. Exempt assignments do not receive a grade. The portfolio examination result
may be down-graded if there are identified weaknesses in the work in one or more capabilities and the student
has declined the opportunity to focus on relevant capabilities by taking an exemption.
Applications will be randomly selected into the quota. All applicants will be notified of the outcome of their
application by email. To apply for an assignment exemption:
Log on to eMed
Go to eMed: Registrations and click on Register Preference in the left hand panel
Select Phase 1, the Course and the Cycle: if you are eligible for an assignment exemption, text to this
effect will appear in RED
Select the Exempted Assignment submission type
Click on the Submit button.
You will receive an emailed acknowledgement of your application. If your application is unsuccessful, you will
need to register for another assignment in the course. If your application is successful, a token entry will be
placed in your portfolio indicating that you were granted an assignment exemption for that course. You will
then be prevented from applying for an exemption in later courses in the phase.

Session 2: TP4 2015
Page 64
Assignments
Assignment 1: Spinal Stenosis
Graduate Capabilities assessed in this assignment
This project focuses on the following capabilities:

The report will also be assessed for each of the generic capabilities (Effective Communication; Self-directed
Learning and Critical Evaluation; and Development as a Reflective Practitioner), available in the Program Guide,
this Course Guide and the Medicine program website: https://medprogram.med.unsw.edu.au/grading
Aims
This assignment will help you to understand the anatomy of the vertebral column and spinal cord related to
spinal stenosis. In addition, you will come to understand the effect of spinal stenosis on spinal nerve function.
In this assignment, you will:
describe the anatomy of the vertebral column and spinal cord related to spinal stenosis;
correlate changes in the relevant anatomy to the signs and symptoms of a patient presenting with spinal
stenosis; and
compare and contrast the types of spinal stenosis and their related signs, symptoms and potential
complications.
This assignment relates to the course theme of degenerative disease.
Task description and time allocation guide

Task 1:
Discuss the anatomy of vertebral column, general arrangement of the spinal cord and the anatomy of a typical
spinal nerve.
Task 2:
Describe spinal stenosis including lateral and central stenosis, and the anatomical structures at risk in each.
Task 3:
Compare and contrast cervical and lumbar spinal stenosis, explaining how the anatomical structures implicated
are related to clinical manifestations, and discuss the possible complications.
For all the above tasks, you should use textbooks, recent reviews and original articles in quality peer-reviewed
journals.
Suggested time allocation:
Week 1-2:
Weeks 3-4:
Week 5:
Research background information on spinal stenosis and its related anatomy.

Research the types of spinal stenosis, and the anatomical basis for the presentation of each type.
Refine, complete and submit your report.
Report requirements
Word limit of 2000 words.

Reports should be formatted in accordance with the specification on the Medicine program website, and
include a word count on the title page. Ensure that you carefully reference your work using the UNSW
Medicine referencing style (APA). Further details at: http://medprogram.med.unsw.edu.au/assignments-andprojects-phase-1#tab-303400342 . Please refer to the Medicine program website for penalties that will be
applied to reports that exceed the maximum length: https://medprogram.med.unsw.edu.au/penalties (login
required).

Session 2: TP4 2015
Page 65
Assignments
Course themes
Assessment criteria
For a P grade, the written report and any supporting file should meet the following criteria:
Focus Capability 1: Using Basic and Clinical Sciences
Provides an appropriate discussion of the anatomy of the vertebral column and spinal cord. (1.1.1
Explains mechanisms that maintain a state of health)
Explains spinal stenosis and compares and contrasts the different types of spinal stenosis. (1.1.4. identifies
components of science in the scenario not studied)
Explains how changes in anatomy caused by spinal stenosis result in clinical manifestations and
complications. (1.1.2 Recognises health problems and relates normal structure and function to
abnormalities).
Focus Capability 2: Patient Assessment and Management
Describes and discusses the relevant anatomy of the spinal column and spinal cord with respect to
symptoms and signs of spinal stenosis (1.3.2 Relates symptoms and signs to relevant underlying basic and
clinical sciences)
Provides an overview of spinal stenosis and its types, clearly explaining the anatomical basis for its clinical
manifestations and complications. (1.3.8 Applies clinical reasoning to relevant health scenarios, including
the identification of key features and clinical patterns.)
Starting references
NIH National Institute of Arthritis and Musculoskeletal and Skin Diseases (2014). What is Spinal Stenosis?
http://www.niams.nih.gov/Health_Info/Spinal_Stenosis/spinal_stenosis_ff.asp
WebMed. Spinal Stenosis Causes, Symptoms, Treatments, Diagnosis http://www.webmd.com/backpain/guide/spinal-stenosis
Fritz, J.M., Delitto, A., Welch, W.C., & Erhard, R.E. (1998) Lumbar spinal stenosis: A review of current
concepts in evaluation, management, and outcome measurements, Archives of Physical Medicine and
Rehabilitation, 79 (6): 700-708
Ehub, A., & Pannullo, S. (2001) Lumbar Stenosis: A Clinical Review. Clinical Orthopaedics & Related
Research. 384: 137-143
Contact:
A discussion regarding this assignment is available through Moodle.

Session 2: TP4 2015
Page 66
Assignment 2: Neoplasia: Educating the Public

Note this assignment has a quota of 25 students. Please register your interest in this assignment by 9 am
st
Monday 21 September.

Effective Communication
Aims
To develop an audio- or audiovisual guide that can be made available (via MP3 players) to lay visitors to the
Museum of Human disease, and that uses specimens in the Museum to illustrate the natural history of benign
and malignant neoplasms.
Course themes and related learning activities

This assignment relates to the course theme of Degenerative disease.
Task description and time allocation guide

1.
2.
3.
4.
5.
6.
First understand the nature of the end product. You will produce an audio or audiovisual guide in a format
suitable for playing on an MP3 player (iPod or equivalent). The audio guide will allow visitors to undertake
a self-paced tour of specimens within the museum (say 5-10, but up to you) that will be of 15-30 min
duration. During that tour, the visitor will be directed to, and learn about, the various selected specimens.
They will learn about their appearance, and they will learn about the effects that that disease had on the
individual concerned (you may use some discretion here in describing a common clinical story). They will
learn about the role of genetic and environmental risk factors in the disease process. Ideally, the visitor will
see the tour as a coherent whole, and will leave with an improved understanding of the nature of
neoplasia, and its effects. The resource should provide a relevant, informative, interesting and accessible
introduction to the topic of both benign and malignant neoplasms, including diagnosis, natural history and
complications.
For the purposes of this project, the target audience of lay visitors means adults (20-80 years of age)
with secondary school levels of English comprehension skills, but little specific knowledge of medical or
biomedical concepts or terminology.
Consider the various specimens available within the Museum of Human Disease that illustrate benign and
malignant neoplasms, and are also of interest to the lay public.
Through work in the course and through your background research, identify the key elements of
information about each specimen and the disorders they represent that you think are important to convey
to the lay audience.
When you are ready, develop an audio or audiovisual file that can be used as the basis of the tour. The file
should convey all relevant information to the lay visitor, and should be self-contained to the extent that
the visitor will be able to complete the tour without having to ask questions or seek instruction from
Museum staff.
The audio file should be in MP3 format. Recording quality audio is a difficult process, and you will not be
judged on this aspect of the work.
Prepare a separate 1000 word report that justifies your selection of the information and specimens that
you have included in your MP3 file. The report should also indicate, where appropriate, how you believe
the resource could be further improved. In addition to responding to the task requirements, you should
reflect in your report on any particular issues that have arisen for you in doing this assignment.

Session 2: TP4 2015
Page 67
Suggested time allocation

Week 2:
Review specimens and read generally on the topic of neoplasia. Identify relevant specimens from
the Museum of Human Disease. Give careful thought to the sequence of events that might relate
individual specimens to each other, and try to link specimens by telling a story about these
relationships.
Weeks 3 & 4: Construct your audio or audiovisual file. Where possible, include colleagues and lay individuals in
an initial evaluation.
Week 5:
Refine the file and write the report.
Week 6:
Submit both the report and the resource.
Report requirements
1000 word report, plus MP3 file. The report should present:
A justification of the information and specimens you included in the MP3 file
An indication of how the resource could be further improved
Reflections on what you learned by doing this project and on the issues encountered
required).
Assessment criteria
Chooses specimens that allow an effective discussion of the natural history and complications of both
benign and malignant neoplasms (1.1.3 Describes the pathophysiological process of health problems and
can explain their basis at the whole person, organ system, cellular and molecular levels).
Through materials presented in the audio or audiovisual file, as well as the written report, demonstrates
an understanding of the relationship between the chosen specimens, as well as the causes, natural history
and complications of the disease processes they represent (1.1.3 Describes the pathophysiological
process of health problems and can explain their basis at the whole person, organ system, cellular and
molecular levels).
Relates the macroscopic appearances of tissues affected by neoplasia to the underlying disease process,
and to the clinical manifestations of neoplasia (1.1.2 Recognizes health problems and relates normal
structure and function to abnormalities).
Focus Capability 2: Effective Communication

Produces an MP3 file or equivalent that would allow a typical lay museum visitor to understand materials
shown within the Museum of Human disease without the need to consult staff or volunteers. [1.4.1
Understands principles of good communication].
Through use of text, voice and image, provides a description of relevant disease processes that would be
clear and accessible to the lay Museum visitor. (1.4.4 Develops clear written/visual information in
relation to health and health promotion for specific target groups).
Uses sequencing of specimens and/or other methods to effectively convey the relationships between
different stages of malignancy (1.4.4 Develops clear written/visual information in relation to health and
health promotion for specific target groups).

Session 2: TP4 2015
Page 68
Starting References:
Kumar, et al., (2013). Chapter 5 in Robbins Basic Pathology (9th ed., pp. 164 168, 207-210). Saunders.
Images of Disease online, UNSW http://iod.med.unsw.edu.au/
Contact:

Session 2: TP4 2015
Page 69
Assignment 3: Immunotherapy for the Treatment of Genitourinary Cancers

Graduate Capabilities assessed in this assignment:

Tumours of the genitourinary (GU) system include renal cell carcinoma and prostate cancer. One recent
treatment strategy for reducing the size of these tumours is immunotherapy. This approach modifies the
immune response of the body to the tumour cells with monoclonal antibodies, tumour vaccines and adoptive
cell therapies. In particular, there are a number of immune checkpoints involved in mediating the immune
response, which can be blocked by this monoclonal antibody approach. Over the past several years, this
clinical strategy has been shown to result in tumour shrinkage in different types of GU cancers.
Aims:
To briefly describe pathophysiological mechanisms that occur in the development of genitourinary (GU)
cancer. Please be sure to focus your discussion on either renal cell carcinoma or prostate cancer for the
assignment.
To discuss the scientific basis for the use of immunotherapy as a treatment approach for GU cancer.
To investigate the evidence for the effectiveness of the use of immunotherapy as a treatment of GU
cancer.
To describe the potential challenges of the use of immunotherapy as a treatment of GU cancer (e.g. side
effects, compliance issues).
Course themes and related learning activities:

This assignment relates to the course theme: The ageing process
Task description:
The task is to research and write a report on use of immunotherapy as a treatment for genitourinary cancers
(choose to focus on either renal cell carcinoma or prostate cancer for your assignment).
Task 1
Review the pathophysiological mechanisms that occur in the development of genitourinary
cancers.
Task 2
Review and discuss the rationale for which immunotherapy is used as a treatment approach for
the treatment of GU cancers.
Task 3
Review the existing evidence for the efficacy of the use of immunotherapy for the treatment of
metastatic GU cancers. Discuss whether this approach is more or less effective compared to
some of the more traditional approaches.
Task 4
Review the potential challenges of the use of immunotherapy for the treatment of GU cancers.
Discuss potential side effects and compliance issues (if any) which are associated with this
approach.
Week 1-2:
Weeks 3-4:
Weeks 5:
Research background information on genitourinary cancers and immunotherapy.

Research the evidence for efficacy and the potential challenges for immunotherapy.
Refine, complete and submit your report.
Report requirements:
The report should be a maximum of 2000 words, including a reflective component.

Session 2: TP4 2015
Page 70
required).
Assessment criteria
Provides a well-researched discussion of the pathophysiology of genitourinary cancers (with a focus on
either renal cell carcinomas or prostate cancer). (1.1.3 Describes the pathophysiological process of
health problems and can explain their basis at the whole person, organ system, cellular and molecular
levels)
Describes the normal function of immune checkpoints and how these may be disturbed in malignancies.
(1.1.3 Describes the pathophysiological process of health problems and can explain their basis at the
whole person, organ system, cellular and molecular levels)
Explains the mechanisms by which immunotherapy is used for the treatment of GU cancers. (1.3.8 Applies
clinical reasoning to relevant health scenarios, including the identification of key features and clinical
patterns)
Gives an accurate, referenced account of standard treatment for genitourinary tumours and compares this
with the use of immunotherapy. (1.3.9 Articulates a general plan of management, consistent with the
pathophysiological model of illness at an elementary level)
Documents and evaluates evidence of efficacy and adverse effects of immunotherapy as a treatment for
GU cancers. (1.3.8 Applies clinical reasoning to relevant health scenarios, including the identification of
key features and clinical patterns)
Bracarda, et al. (2015). Immunologic Checkpoints Blockade in Renal Cell, Prostate, and Urothelial
Malignancies. Seminars in Oncology, 42 (3), pp 495-505
Manzo, et al (2015) Antigen-specific T cell therapies for cancer. Human Molecular Genetics, 2015, 17.
Silvestri et al (2015) Beyond the Immune Suppression: The Immunotherapy in Prostate Cancer. Biomed Res
Int. 2015.:794968. doi: 10.1155/2015/367354. Epub 2015 Jun 16.
Raman, et al. (2015) Immunotherapy in Metastatic Renal Cell Carcinoma: A Comprehensive Review.
Biomed Res Int. 2015:367354. doi: 10.1155/2015/367354. Epub 2015 Jun 16.
Van Dodewaard-deJong, et al. (2015) New Treatment Options for Patients with Metastatic Prostate
Cancer: What Is The Optimal Sequence? Clin Genitouriny Cancer. 13(4):271-9.
Weber, J.S. (2014) Current perspectives on immunotherapy. Semin Oncol. 41 Suppl 5:S14-29.
Surolia, et al. (2014) Recent advances in the use of therapeutic cancer vaccines in genitourinary
malignancies. Expert Opin Biol Ther. 14(12):1769-81.
Contact:

Session 2: TP4 2015
Page 71
Assignment 4: Euthanasia and Ethics

IMPORTANT NOTE: This is an exercise in academic research of the issues surrounding the ethics of
euthanasia. You do not need to interview palliative care or other specialists in the area.
Graduate capabilities assessed in this assignment:
Understanding ethics and legal responsibility
Social and cultural aspects of health and disease
Aims:
This assignment asks you to investigate the notion of euthanasia and the moral arguments both for and
against it. You will also be required to investigate some of the social and cultural attitudes towards euthanasia
and the resultant legislation that have been set up in some countries to allow it.

This assignment relates to the course theme of Death and dying.
Task description and time allocation guide:

1.
2.
3.
One of the major difficulties in discussions about euthanasia is the confusion over terminology. Define and
discuss the differences between the terms: active euthanasia; passive euthanasia; mercy killing;
physician-assisted suicide; and the principle of double effect. Explain what legislation exists in relation to
these terms both in Australia and in one other country (where legislation is different). What are some of
the practical implications of Australian legislation for medical practice?
Investigate some of the practical and moral arguments both for and against euthanasia. Be sure to refer to
some of the contemporary bioethicists, such as James Rachels, Daniel Callaghan and Peter Singer, who
have written on this topic, as well as the medical literature (and the ethics textbook which has an excellent
section on euthanasia). In this section of your report you should also discuss some of the cultural, religious
and social issues that affect the discussion of euthanasia.
After reading about the practical and moral arguments for and against euthanasia, think about it and
express your reasoned opinion regarding whether or not it should be legal in Australia.

Weeks 1 & 2 Gain an understanding of the related terms and research the topic.
Weeks 3
Research the topic.
Weeks 4
Complete report, including reflection.
Week 5
Submit the correct and final version.
2,000 word report. In addition to responding to the task questions, you should reflect on your own views on
euthanasia and whether they have been affected or changed by completing the above tasks.
required).

Session 2: TP4 2015
Page 72
Assessment criteria
Focus Capability 1: Understanding ethics and legal responsibility
Defines terms related to euthanasia appropriately and discusses the practical application of these terms in
medicine. (1.7.4 Identifies and discusses the ethical aspects of scenarios and other experiences).
Explores relevant legislation regarding euthanasia in Australia and one other country. (1.7.7 Understands
the legal responsibilities of health professionals).
Discusses moral arguments for and against euthanasia, with reference to relevant literature. (1.7.4
Identifies and discusses the ethical aspects of scenarios and other experiences).
Reflects on their own opinion regarding euthanasia and whether the process of completing this assignment
has affected their opinion in any way. (1.7.1 Explores the psychological, social and cultural determinants
of ones own values and can discuss the relevance and appropriateness of personal values in clinical
medicine).
Focus Capability 2: Social and cultural aspects of health and disease
Discusses the social and cultural factors that affect the acceptance or rejection of euthanasia. (1.2.1
Identifies environmental, psychological, social and cultural issues which contribute to health problems in
a scenario (e.g. sexuality, stress, family relationships, risky behaviours).).
Discusses the stance of some religious and medical bodies (such as the AMA) in relation to euthanasia
(1.2.1 Identifies environmental, psychological, social and cultural issues which contribute to health
problems in a scenario (e.g. sexuality, stress, family relationships, risky behaviours).).
Starting References
Kerridge, I., Lowe, M., McPhee, J. (2005) Ethics and law for the health profession. (2nd ed.) Federation
Press.
Singer, P. (1993) Practical ethics. 2nd edition, Cambridge University Press.
Contact:

Session 2: TP4 2015
Page 73
Assignment 5: To supplement or not? Weighing up Calcium and Vitamin D

supplementation in reducing osteoporosis risk. (QMP assignment)
Using basic and clinical sciences
Self-directed learning and critical evaluation
Aims
This assignment will give you a better understanding of bone metabolism and the effectiveness of calcium and
vitamin D supplementation in reducing risk of osteoporosis in the elderly. As this is a QMP assignment, you will
learn more skills in critical appraisal and the understanding of research studies and how to interpret their
results.

This assignment relates to the course themes of:
The ageing process
Degenerative disease
The course scenario (Scenario 1. Alma Jones) and associated learning activities on bone metabolism and
metabolic bone disease are relevant to this topic. The QMP lectures, online tutorials and practicals will help
you with the evaluation.
Background
The use of calcium and vitamin D supplementation for the reduction of risk of osteoporosis and its clinical
outcomes in the elderly remains controversial. The treatment is not easy to research in the population at risk,
and the findings are complex to convey to health workers and patients.
Your first task is to understand and provide the scientific background to the treatment using up-to-date
scientific literature. As there remains confusion regarding whether these supplements can help prevent the
worst osteoporosis outcomes without significant harms, you will carry out a full critical appraisal on one of the
seminal papers (Dawson-Hughes et al from 1997) that is still cited in favour of treatment. You will then search
for current secondary sources (such as meta-analyses, systematic reviews, review articles, etc) to find the best
and most current evidence-based resources to determine what the current evidence balance shows compared
to the original research. Is the benefit outweighed by the harm or vice versa? Finally you will make a
recommendation using your research as to the current safe, best practice.
Tasks
Task 1: What is the science behind this treatment?
Carry out a literature search to find and review the scientific background behind the use of calcium and
vitamin D in reducing the risk of osteoporosis and its outcomes.
You will need to understand and be able to describe the basic pathophysiology and therapeutics
underlying this topic.
Write up as section 1 in your report (Max. 600 words)
By way of an introduction to your report, it would be sensible to start with a definition and some basic
epidemiology and clinical details.
Then present the scientific information as a succinct background section to summarise the rationale for
this treatment approach.
Use your own flow diagrams, visual aids, etc. to help in this explanation.
The assessment criteria associated with this first task are as follows:
Briefly describes the pathophysiology and clinical presentation of osteoporosis.
Succinctly explains (assisted by original and cited diagrams etc.) the main therapeutic processes by which
calcium and vitamin D are thought to reduce the risk of osteoporosis in the elderly.

Session 2: TP4 2015
Page 74
Task 2: Does the science actually work in the clinical environment?

Using an EBM process, find the best evidence to provide a basis for recommending whether or not calcium and
vitamin D supplementation should be routinely prescribed to the elderly in order to reduce the risk of
osteoporosis and its outcomes.
EBM STEP 1 - ASK:
Form a specific PICO style research question(s) to help you research this topic. Put this at the top of your
search table.
EBM STEP 2 - ACQUIRE:
Use keywords from this PICO question to carry out a structured literature search to find the best
secondary source evidence available to answer this question.
Record your full research question and the full search strategy that you carry out with the key results as
follows:
1. You should find this secondary source evidence from reputable and current sources. We suggest that
you search: in Medline under evidence-based reviews; the Cochrane database to find systematic
reviews and meta-analyses; and via the web to find evidence-based, up-to-date clinical practice
guidelines published by local and international medical organisations.
2. We suggest that you start the literature search in the Medline database. Then use these terms in
other relevant databases. Use mapping to the subject headings in Medline and make use of explode /
focus / limits and Boolean operators as necessary. Note: Failure to do this will result in a lower grade
for the focus SDL / CE grade.
Append this literature search summary as Appendix 1 to your assignment report.
1. This summary search table should show enough information for the search to be repeatable and
demonstrate your appraisal method.
2. It should include columns for: Resource used: Library Database used or Web search engine used and
method (E.g. advanced); Keywords/ MESH terms used; Focus/ Explode; Limits used; Boolean
operators; Number of Hits; Key articles found; and short summary of CRAAP for all sources used in the
report (see below).
EBM STEP 2-3 ACQUIRE-APPRAISE:
Choose the best evidence available according to a sensible rubric for evaluation of reliability and relevance
of each source (e.g. CRAAP: http://web.med.unsw.edu.au/infoskills/internet4.htm).
The final columns of the search strategy table should show the number of hits for each complete search
set, the useful articles found and why they were chosen (e.g. summarise your CRAAP for each chosen
article).
EBM STEP 3 - APPRAISE:
Read and interpret all the useful evidence from your focused search. Summarise the CRAAP evaluations in
the final column of your search summary table.
Using the QMP 8-point Critical Appraisal Multi-use worksheet (link provided in the section, Useful QMP
sources for the EBM task) carry out a full appraisal worksheet for the study given below and append this as
Appendix 2. This was one of the first major studies to show the benefits of supplementation for this
condition:
Dawson-Hughes, B., Harris, S.S., Krall, E.A., and Dallal, G.E. (1997). Effect of calcium and vitamin D
supplementation on bone density in men and women 65 years of age or older. N Engl J Med. 337, 670-6.
The following assessment criteria relate to the EBM steps 1-3 (inclusive) described above:
Conducts a thorough literature search to find the best secondary source evidence to answer the
research question. This search is fully documented and appended in a simple table, which includes a
basic evaluation of all the key evidence.
Completes and appends a full and clear critical appraisal of the given study using the QMP CA Multiuse worksheet.

Session 2: TP4 2015
Page 75
EBM STEP 4 APPLY: Consider - Is there a current safe and effective approach to take for the healthy elderly
population in Australia?
This constitutes section 2 of your report:
Discussion:
In the text of the report, using findings from your appraisal of the Dawson-Hughes et al (1997) paper and
the best of the secondary sources you have found, critically discuss the benefits and harms of calcium and
vitamin D supplementation in reducing the risk of osteoporosis and its outcomes in the elderly. (Approx.
700 words)
Conclusion:
Write a succinct conclusion, making considered recommendations for the most effective and safe
treatment approach to reduce the risk of osteoporosis in the elderly. (Approx. 3-400 words)
The associated assessment criterion for this particular task is as follows:
Discusses all the useful evidence for this therapeutic intervention regarding benefits and harms, and makes
considered, evidence-based recommendations for reduction of risk of osteoporosis in the elderly.
EBM STEP 5 - ASSESS:
Reflect on the EBM process that you have undertaken and also on your learning about the scientific
content of this assignment. Write this up as your reflective section. This will be assessed under the generic
Reflective Practitioner capability as usual. (Approx. 3-400 words)
Report requirements
The report should be a maximum of 2000 words, including a reflective component.
required).
Time allocation guide

Weeks 1-2
Weeks 2-3
Week 3
Weeks 3-4
Week 4
Week 5
Choose the assignment and register. Begin searching for the scientific background. Start the EBM
steps 1 and 2.
Finish the literature searches needed. Summarise your search for the secondary sources as a table
in Appendix 1. Write up the descriptive scientific background section.
Carry out Step 3: Appraise the secondary sources. Full written critical appraisal of the study
provided, presented in the worksheet format as Appendix 2.
Write the appraisal section (discussion section) of the assignment. Use these findings to write the
recommendations as a conclusion to your report. (Step 4 of EBM: Applying).
Final edit and proof read: Have you answered the assessment criteria? Finalise your Reflection
(Step 5 of EBM: Audit/ Assessing).
Submit the correct and final version.
Assessment criteria
Focus Capability 1: Using basic and clinical sciences
Briefly describes the pathophysiology and clinical presentation of osteoporosis. (1.1.1 Explains
mechanisms that maintain a state of health)
Succinctly explains (assisted by original and cited diagrams etc.) the main therapeutic processes by which
calcium and vitamin D are thought to reduce the risk of osteoporosis in the elderly (1.1.3 Describes the
pathophysiological process of health problems and can explain their basis at the whole person, organ
system, cellular and molecular levels)

Session 2: TP4 2015
Page 76
Focus Capability 2: Self-directed learning and critical evaluation

(1.6.4 Demonstrates the following skills in Phase 1: formulating and applying appropriate information
searching strategies; using databases such as Medline and other information sources appropriately;
appraising the quality and relevance of the information found; using appropriate citation standards.)
Conducts a thorough literature search to find the best secondary source evidence to answer the research
question. This search is fully documented and appended in a simple table, which includes a basic
evaluation of all the key evidence.
Completes and appends a full and clear critical appraisal of the given study using the QMP CA Multi-use
worksheet.
Discusses all the useful evidence for this therapeutic intervention regarding benefits and harms, and makes
considered, evidence-based recommendations for reduction of risk of osteoporosis in the elderly.
The generic capabilities, Effective communication, Self-directed Learning and Critical Evaluation, and
Development as a Reflective Practitioner will be assessed using the generic criteria listed in this course guide,
the Program guide and the course notes. https://medprogram.med.unsw.edu.au/grading
Note: the EBM search [in Task 2] will be assessed within the focus capability above as Appendix 1.
References:
The trial for the full 8 point QMP CA worksheet appraisal:

Dawson-Hughes, B., Harris, S.S., Krall, E.A., and Dallal, G.E. (1997). Effect of calcium and vitamin D
supplementation on bone density in men and women 65 years of age or older. N Engl J Med. 337, 670-6.
A useful older secondary source on this topic. A good starting point for your understanding and your full
search of current secondary sources of evidence:
Tang, B.M.P., Eslick, G.D., Nowson, C., Smith, C. and Bensoussan, A.(2007). Use of calcium or calcium in
combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years
and older: a meta-analysis. The Lancet, 370, (9588), 657-666.
Useful QMP sources for the EBM task

The QMP AEA and previous lectures / practicals will give you background on EBM and understanding /
interpreting evidence. The QMP online tutorials 4 and 5 provide information on critical appraisal and using the
QMP critical appraisal worksheet. QMP online tutorials 9 and 10 will give you information about how to
interpret findings from meta-analyses etc., in terms of benefit and risk (e.g. odds, risks and NNT and NNH).
UNSW 3802 Medicine Information skills online tutorial re the CRAAP process. Other modules in this can
help you for the search/ appraisal aspects of the tasks:
http://web.med.unsw.edu.au/infoskills/internet4.htm
QMP online tutorials 4, 5, 9, 10: http://web.med.unsw.edu.au/QMP/QMPHome.htm
QMP critical appraisal worksheet (8 point version) is available at:
http://web.med.unsw.edu.au/QMP/CA_worksheet_2014_UNSW.doc
CEBM Oxford. Explanation of numbers needed to treat NNT: http://www.cebm.net/number-needed-totreat-nnt/
Contact:

Session 2: TP4 2015
Page 77
Projects
Project 1: Arthroscopic Repair vs Total Knee Replacement
This project is suitable for 3 to 5 students (optimally 4).
Graduate capabilities assessed in this project:

Learning and Critical Evaluation; and Teamwork), available in the Program Guide, this Course Guide and the
Medicine program website: https://medprogram.med.unsw.edu.au/grading
Aims:
To discuss the anatomy of the knee joint and relate structure to function.
To briefly describe the degenerative conditions of the knee that benefit from knee surgery.
To describe how arthroscopic surgery of the knee is performed, indicating which degenerative knee
conditions it is suitable for and outlining any potential complications.
To describe how total knee replacement (arthroplasty) is carried out, indicating the potential
complications.
Contrast these two surgical approaches to knee problems. Compare the costs and benefits of each and
outline under what circumstances you would recommend each to a patient.

This project relates to the course themes: Degenerative disease.

Each of the following tasks may be assigned to one person, but all group members must be familiar with the
outcomes of the work by all other group members.
Task 1
Research the anatomy and biomechanics of the knee joint. Your answer should primarily focus on the
relationship between structure and function and go beyond a simple description of anatomical features.
Task 2
Describe briefly the types of degenerative conditions that would benefit from knee surgery. You should
provide only enough detail to understand why surgery is required. Detailed discussion of causation and
epidemiology is not required.
Task 3
Describe how arthroscopic knee surgery is performed. Indicate the degenerative knee conditions that it is
suitable for and discuss the possible outcomes for the patient. What post-operative regimes must be followed
by the patient?
Task 4
Describe how total knee arthroplasty (TKA) is carried out. What are the potential complications? What postoperative regimes must be followed by the patient?
Task 5
Compare and contrast the arthroscopic and TKA approach to degenerative knee problems. What are the costs
and benefits of each? Under what circumstances would you recommend each to a patient?
Weeks 1 - 2:
Weeks 3 -4:
Weeks 5-6:
Week 7:
Have an initial meeting of team members to allocate tasks. Research background information
on knee biomechanics and degenerative conditions of the knee.
Review progress with colleagues in the project team. Critically evaluate and summarise the
literature on arthroscopy vs TKR. Begin to assemble the report outlining the scientific issues
and identify aspects of the project that still need research.
Finish writing and reviewing the report and write reflection.
Submit final and correct report into eMed

Session 2: TP4 2015
Page 78
Report requirements
Maximum 2,500 word report including appropriate illustrations of knee structure at a level which goes beyond
that provided in lectures and practical classes. You should provide some illustrations of common indications for
knee surgery. You must also illustrate findings from surgical studies that show how the relevant procedures are
performed and what the complications may be. The report should include tabular presentation of patient
management principles, outcomes and guidelines.
You will achieve a higher mark if you engage in critical thinking, i.e. contrast points of view of different authors
and show some ability to differentiate between good and poor clinical arguments. This requires you to form an
opinion and defend it, rather than simply repeating what is written in your sources.
required).
Assessment criteria
Focus Capability 2: Patient assessment and management

Describes how arthroscopic knee surgery is performed. Indicates the degenerative knee conditions that it
is suitable for and discusses the possible outcomes for the patient. Describes the post-operative regimes
which must be followed by the patient (400 words recommended) (1.3.9 Articulates a general strategy of
management, consistent with the pathophysiological model of illness at an elementary level that
includes an understanding of foundation principles; 1.3.8 Applies clinical reasoning to relevant health
scenarios, including the identification of key features and clinical patterns).
Describes how total knee arthroplasty (TKA) is performed. Describes the potential complications and the
post-operative regimes that must be followed by the patient (400 words recommended) (1.3.9 Articulates
a general strategy of management, consistent with the pathophysiological model of illness at an
elementary level that includes an understanding of foundation principles; 1.3.8 Applies clinical reasoning
to relevant health scenarios, including the identification of key features and clinical patterns).
Compares and contrasts arthroscopic and TKA approaches to degenerative knee problems. Describes the
costs and benefits of each. Describes the circumstances under which each would be recommended to a
patient. (400 words recommended) (1.3.9 Articulates a general strategy of management, consistent with
the pathophysiological model of illness at an elementary level that includes an understanding of
foundation principles; 1.3.8 Applies clinical reasoning to relevant health scenarios, including the
identification of key features and clinical patterns).
Reflection on Teamwork
In meeting the generic Teamwork capability requirements, you should evaluate how effectively the project
group worked as a team and analyse the role of each project group member using an appropriate theoretical
framework from the Teamwork for Group projects webpage:
https://medprogram.med.unsw.edu.au/teamwork-group-projects
You should provide an appendix (not included in the word count) that shows a record of the interactions
between your group members, whether by email or group meetings. (1.5.3 Analyses and evaluates own roles
and contributions to group work using own observations and feedback from others)
Session 2: TP4 2015
Page 79
Projects
Focus Capability 1: Using basic and clinical sciences

Describes anatomical features of the knee joint that contribute to joint function (400 words
recommended). (1.1.1 Explains mechanisms that maintain a state of health)
Briefly describes the types of degenerative conditions that might benefit from knee surgery (400 words
recommended). (1.1.3 Describes the patho-physiological process of health problems and can explain
their basis at the whole person, organ system, cellular and molecular levels)
Barlow T, Plant CE (2015) Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study.
BMC Musculoskeletal Disorders. DOI 10.1186/s12891-015-0537-y
Carr, A.J., Price, A.J., Glyn-Jones, S., and Rees. J.L. (2015) Advances in arthroscopy indications and
therapeutic applications. Nat Rev Rheumatol 11: 77-85.
Fibel, K.H., Hillstrom, H.J., and Halpern, B.C. (2015) State-of-the-art management of knee osteoarthritis.
World Journal of Clinical Cases. DOI: 10.12998/wjcc.v3.i2.89
Howell, R., Kumar, N.S., Patel, N., and Tom, J. (2014) Degenerative meniscus: Pathogenesis, diagnosis and
treatment options. World Journal of Orthopaedics 5: 597-602.
Thorlund, J.B., Juhl, C.B., Roos, E.M., and Lohmander, L.S. (2015) Arthroscopic surgery for degenerative
knee: systematic review and meta-analysis of benefits and harms. BMJ 10.1136/bmj.h2747.
Contact:
A discussion board regarding this project will be available in Moodle.

Session 2: TP4 2015
Page 80
Project 2: Chemotherapy-Induced Peripheral Neuropathy (CIPN)

This project is suitable for 4 - 5 students.
Graduate Capabilities assessed in this project

Aims
Overview: Chemotherapy-induced peripheral neuropathy (CIPN) accompanied by neuropathic pain is a
debilitating adverse effect of chemotherapy treatment for cancer that severely impacts the quality of life of 3070% of patients. The pathophysiology of CIPN remains poorly understood and treatments to prevent CIPN are
inadequate. Chemotherapy schedule modification is normally required to limit CIPN progression, which may
compromise the effectiveness of cancer treatment.
This project will help you to understand the neurotoxic effects of chemotherapy in the peripheral nervous
system and the management of CIPN. Specific aims are:
To describe the common symptoms, prevalence, and risk factors of CIPN
To understand the mechanisms underlying CIPN
To briefly discuss current diagnosis and clinical assessment strategies
To outline the management of CIPN including pharmacological and non-pharmacological measures
To reflect on the psychological and physical impact of CIPN on patients

This project relates to the course theme: Death, dying and palliative care
Task description
The task is to research and write a report on the development of CIPN in cancer patients and cancer survivors.
Task 1 Describe the common symptoms that occur during the development of CIPN, the prevalence of the
condition, and factors reported to alter the risk of CIPN
Task 2 Discuss the pathophysiological mechanisms involved in the development of CIPN and how
chemotherapeutic drugs cause peripheral neurotoxicity
Task 3 Review the principal diagnosis and clinical assessment strategies of CIPN
Task 4 Discuss the pharmacological and non-pharmacological management of CIPN, and how the
symptoms can be managed or prevented in patients requiring ongoing chemotherapy
Task 5 Reflective component: describe what you have learned about the impact of cancer treatments on
patients

Weeks 1 - 2:
Weeks 3 -4:
Weeks 5-6:
Week 7:
Have an initial meeting of team members to allocate tasks. Research background information
on the pathophysiology, assessment, and management of CIPN.
Review progress with colleagues in the project team. Critically evaluate and summarise the
literature. Begin to assemble the report outlining the scientific issues and identify aspects of
the project that still need research.
Finish writing and reviewing the report and write reflection.
Submit final and correct report into eMed
Report requirements
Maximum 2500 word report.

In addition to responding to the task questions, you should also reflect on what you have learned by doing this
project and on the issues, including teamwork issues, encountered.
Session 2: TP4 2015
Page 81
required).
Assessment criteria
Presents an accurate overview of CIPN, including symptomatology, prevalence, and risk factors (1.1.2
Recognises health problems and relates normal structure and function to abnormalities)
Appropriately describes the pathophysiological mechanisms of CIPN (1.1.3 Describes the
pathophysiological process of health problems and can explain their basis at the whole person, organ
system, cellular and molecular levels).
Describes how the mechanisms of action of chemotherapeutic drugs may result in peripheral neuropathy
(1.3.2 Relates symptoms and signs to relevant underlying basic and clinical sciences).
Provides an appropriate review of the clinical assessment, as well as the pharmacological and nonpharmacological management, of CIPN (1.3.8 Applies clinical reasoning to relevant health scenarios,
including the identification of key features and clinical patterns; 1.3.9 Articulates a general strategy of
management, consistent with the pathophysiological model of illness at an elementary level that includes
an understanding of foundation principles).
Assesses the impact of chemotherapy on patients and ongoing management to prevent/treat CIPN (1.3.8
Applies clinical reasoning to relevant health scenarios, including the identification of key features and
clinical patterns).
Starting References
Sisignano, M., Baron, R., Scholich, K., & Geisslinger, G. (2014) Mechanism-based treatment for
chemotherapy-induced peripheral neuropathic pain. Nat Rev Neurol. 2014 Dec;10(12):694-707.
Carozzi, V.A., Canta, A., & Chiorazzi, A. (2015) A. Chemotherapy-induced peripheral neuropathy: What do
we know about mechanisms? Neurosci Lett. 2015 Jun 2;596:90-107.
Seretny, M., et al. (2014). Incidence, prevalence, and predictors of chemotherapy-induced peripheral
neuropathy: A systematic review and meta-analysis. Pain. 2014 Dec;155(12):2461-70.
Poupon L, et al. (2015). Minimizing chemotherapy-induced peripheral neuropathy: preclinical and clinical
development of new perspectives. Expert Opin Drug Saf. 2015 Aug;14(8):1269-82.
Kim, J.H., Dougherty, P.M., & Abdi, S. (2015). Basic science and clinical management of painful and nonpainful chemotherapy-related neuropathy. Gynecol Oncol. 2015 Mar;136(3):453-9.
Park, S.B., et al. (2013). Chemotherapy-induced peripheral neurotoxicity: a critical analysis. CA Cancer J
Clin. 2013 Nov-Dec;63(6):419-37.
Pachman, D.R., Watson, J.C., & Loprinzi, C.L. (2014). Therapeutic strategies for cancer treatment related
peripheral neuropathies. Curr Treat Options Oncol. 2014 Dec;15(4):567-80.
Contact:
A discussion regarding this project is available through Moodle.

Session 2: TP4 2015
Page 82
Project 3: Interview with Palliative Care Patients: Metastatic Malignancy

Compared with End Stage Chronic Kidney Disease
Note: this project has a quota of 5 groups. Please register your interest in this project through the process
described in the introduction to assessment above for projects with quotas. Each group should have 4 to 6
students. Students are to contact Frank Brennan regarding the interviews before the end of week 2.
Graduate capabilities assessed in this project

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

Death, dying and palliative care

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

Session 2: TP4 2015
Page 83
A guide for time allocation:

Tuesday of Week 2:
Weeks 2 and 3:
Weeks 4-6:
Week 7:
Organise your interviews. You must contact Dr Frank Brennan to be assigned

patients.
Contact interviewees and organise a time to meet them. Prepare questions and
approach.
Conduct the interviews. Interviews should be completed by week 4.
Write up the interviews and prepare final submission.
Submit correct and final report into eMed.
A written report, maximum 2,500 words.
required).
Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria:
Focus Capability 1: Patient assessment and management
Adequately describes, compares and contrasts the perspectives and palliative care needs of patients with
metastatic malignancy and end stage Chronic Kidney Disease on dialysis. (1.3.3 Understands patients
should share decision-making and planning of their treatment, including communication of risk and
benefits of management options. 1.3.2 Relates symptoms and signs to relevant underlying basic and
clinical sciences).
Focus Capability 2: Development as a Reflective Practitioner
Critically evaluates communication/interviewing skills employed. (1.8.5 Analyses experiences and
feedback in terms of strengths and weaknesses, identifies barriers to improvement in all capability areas
and addresses these barriers, or articulates realistic and coherent plans to do so).
Adequately discusses any difficulties in the interviewing process. (1.8.5 Analyses experiences and
Openly discusses personal feelings and reactions to the individuals encountered and the content of what
they said. (1.8.4 Provides accurate and neutral descriptions of own behaviour, emotions, and intentions.
Analyses the impact of own and others behaviour and cultural background on self and others).
Honestly evaluates whether this project has altered personal views about Palliative Care. (1.8.4 Provides
accurate and neutral descriptions of own behaviour, emotions, and intentions. Analyses the impact of
own and others behaviour and cultural background on self and others).
In meeting the generic Teamwork capability requirements ((1.5.3 Analyses and evaluates own roles and
contributions to group work using own observations and feedback from others), you should evaluate how
effectively the project group worked as a team and analyse the role of each project group member using an
appropriate theoretical framework from the Teamwork for Group projects webpage:
Starting references:
These are given as a guide. It is expected that you will look at other sources than these.
Barbato, M. (2005) Care of the dying patient. Internal Medicine Journal 35: 636-637.
Session 2: TP4 2015
Page 84
Germain, M.J. (2009) Renal supportive care: why now? Progress in Palliative Care 2009; 17(4): 163-164.
(Guest Editorial).
Cohen, A.M., Moss, A.H., Weisbord, S.D., Germain, M.J. (2006) Renal Palliative Care. Journal of Palliative
Medicine 2006; 9(4): 977-992.
Academic contact: Please contact Dr Brennan, who will assign patients for interviews
Dr Frank Brennan. Email: fpbrennan@ozemail.com.au

Session 2: TP4 2015
Page 85
Project 4: Interview with Health Professionals Working in Palliative Care

Note: this project has a quota of 10 groups. Please register your interest in this assignment through the
process described in the introduction to assessment above for projects with quotas. Each group should have
4-6 students. Students are to contact Jan Maree Davis regarding the interviews before the end of week 2.
Graduate Capabilities assessed in this project:
Teamwork
Aims:
The aims of this Project are for students to gain an insight into the world of health professionals who work in
Palliative Care, their personal and professional motivations, their professional challenges and the way their
work influences them as individuals.
Death Dying and Palliative Care
Each group will be assigned 2 health professionals working in Palliative Care:
1. A palliative care physician, and
2. An allied health professional e.g. palliative care nurse (hospice); palliative care nurse (community
palliative care service); physiotherapist; social worker; pastoral care officer; co-ordinator of hospice
volunteers.
Each individual health professional can be interviewed by one group only.
You will interview the 2 assigned health professionals. You must contact Dr Jan Maree Davis to be assigned
professionals for interview.
Please note:
All information shared with you is strictly confidential and must not be discussed outside the group. When
writing up the report, you must ensure all references to the place the person works, and their names, are not
used. Pseudonyms are acceptable.
Your interview must be wide-ranging and creative, as well as reflective. This should be a narrative work.
Suggested questions may include:
Why did you enter your profession?
Why did you enter the area of Palliative Care?
What are the best aspects of your work?
What are the worst aspects of your work?
Describe the nature of your work in detail.
What advice would you give to medical students about this area?
Does it ever become depressing?
How do you cope with sadness? What are your personal strategies?
How do you deal with difficult patients or their relatives?
Do you go to the funerals of your patients?
You will summarise the main points you have learnt from the interviews with the two health professionals.
Your summation should include a discussion of similarities and differences, in the roles, and impacts of the
work, in the 2 health professionals interviewed
You will be expected to include a reflection consistent with the capability of Development as a Reflective
Practitioner. This may include a critical incident analysis, identification of problems encountered and how they
Session 2: TP4 2015
Page 86
could be overcome next time, comparison of this experience with an earlier experience, reflection on feedback
on an oral presentation.
As a guide for time allocation:
Tuesday of Week 2: Organise your interviews. You must contact Dr Jan Maree Davis to be assigned
professionals. Contact interviewees and organize a time to meet them. Prepare
questions and approach.
Weeks 2 and 3:
Conduct the interviews. Interviews should be completed by week 4.
Weeks 4 to 6:
Write up the interviews and prepare final submission.
Week 7:
Submit correct and final report into eMed.
The required length of the Group Project is 2,000 to 2,500 words.
Reports should be submitted in 12 point Times New Roman font, double or at least one and a half spaced.
required).
Assessment criteria:
For a P grade, the written report and the resource should meet the following criteria:
Focus Capability: Teamwork-note two teams to be described
Describes the role and responsibilities of health professionals working in Palliative Care, as part of a
healthcare team. (1.5.5 Explains roles and functions of other health professionals in patient care).
Discuss how you participated as a group. Analyse how well the group worked together on the Project,
what styles contributed, what aspects of the group work were found unhelpful. (1.5.3 Analyses and
evaluates own roles and contributions to group work using own observations and feedback from
others).
Focus Capability: Development as a Reflective Practitioner
Critically evaluates communication/interviewing skills employed. (1.8.5 Analyses experiences and
Adequately discusses any difficulties in the interviewing process. (1.8.5 Analyses experiences and
Openly discusses personal feelings and reactions to the individuals encountered and the content of what
they said. (1.8.4 Provides accurate and neutral descriptions of own behaviour, emotions, and intentions.
Analyses the impact of own and others behaviour and cultural background on self and others).
Honestly evaluates whether this project has altered personal views about Palliative Care. (1.8.4 Provides
accurate and neutral descriptions of own behaviour, emotions, and intentions. Analyses the impact of
own and others behaviour and cultural background on self and others).
You must provide evidence of thoroughness of interviewing the health practitioners. Please include transcripts
of interviews in an appendix

Session 2: TP4 2015
Page 87
Starting references: These are given as a guide. It is expected that you will look at additional sources too.
Clark, D. (2007) From margins to centre: a review of the history of palliative care in cancer. Lancet
Oncology 8: 430-438.
Kearney, M. (1992) Palliative Medicine just another specialty? Palliative Medicine; 6: 39-46.
Barbato, M. (2005) Care of the Dying Patient. Internal Medicine Journal. 35: 636-637.
Search on: Palliative Care on Google.
For Journals relating to Palliative Care visit: http://www.hospicecare.com/journals_publications.htm
Contacts:
If you are successful in registering for this Project-you need to contact Dr Davis, who will give you contact
details of the health professionals you will be interviewing.
Dr Jan Maree Davis, Palliative Care Consultant, St George Hospital, Kogarah. Email:
janmaree.davis@sesiahs.health.nsw.gov.au

Session 2: TP4 2015
Page 88
Project 5: Integrating learning through developing questions for an online

tutorial
This project is suitable for 4-6 students. A mix of first and second year students is mandatory.
Graduate Capabilities assessed in this project

Self-Directed Learning and Critical Evaluation
Teamwork
Aims
The aims of this project are:
1. To develop a deep understanding of the learning issues that arise from within the Osteoporosis (Alma
Jones) or the Arthritis (The Rheumatology A Team) scenarios by using appropriate learning strategies.
2. To develop skills in integrating knowledge from various disciplines.
3. To develop skills in self-directed learning and collaborative learning (teamwork).
Task description
Students undertaking this project are strongly advised to attend the project briefing session in Week 2, 24
September 2015. This session will outline the task, explain how adaptive tutorials are designed and explain the
expectations of the final submission.
1.
2.
3.
4.
Identify the key learning issues that arise from the scenario.
Develop a deep understanding of these issues through scheduled and self-directed learning activities and
group discussion. Prioritise 3 issues to focus on.
Attempt at least one of the adaptive online tutorials that are available for each week of this course. This
will provide you with an example of the styles of questions that can be used in adaptive online tutorials.
Develop six tutorial questions focussing on the above three issues. Discuss the questions within your
project group and ensure that the questions:
require a higher level of thinking and not mere recall of information. (For example, better questions
may require integration of content across disciplines, problem solving, application of content
knowledge to new situations etc.); and
cover a range of graduate capabilities that include: Using Basic and Clinical Sciences, Patient
Assessment and Management, Social and Cultural Aspects of Health and Disease, Ethics and Legal
Responsibilities.
As far as possible, ensure that the questions require answers that integrate knowledge across various
disciplines.
Generate model answers for the questions. Include summary points to justify your answer. Consider common
mistakes that your peers may make, and include feedback you might provide to address these common
misconceptions.
5.
Test the questions and feedback that you develop through peer-teaching in your scenario group. Continue
to note common misconceptions and develop relevant feedback. Time has been allocated in SGS 6 8 & 9
for this purpose. If additional time is required, this should be arranged with your scenario group members
outside of scheduled SG time.
This project is suitable for 4-6 students. A mix of first and second year students is mandatory.

Session 2: TP4 2015
Page 89
Report requirements
Your report should include:
1. Your tutorial questions and a brief discussion of the content that was relevant when formulating the model
answers to these questions. For example, this brief discussion could outline the relevant content areas, the
significant links between them, and the important concepts that should be understood in order to
effectively answer the questions.
2. An appendix that summarises the questions, the model answers and feedback to common misconceptions.
These may be provided using the PowerPoint template provided or a table as below. The appendix should
also include a flow diagram that demonstrates how the flow of the online tutorial will adapt to the
learners input e.g. a certain misconception might lead to re-direction to a screen with further
information on that topic before reattempting the question.
Question
Model answer
Common misconception 1
3.
Feedback
Feedback
Feedback
Feedback
Feedback
A section that reflects on how your group worked together as a team. This section should:
a.
Discuss how your project group collaborated to ensure that all project group members achieved a
sound understanding of the learning issues, and decided on the content for the tutorial, and
achieved the aims of the project. This should include a discussion of the peer teaching strategies
used by your group and the extent to which these strategies were effective.
b.
Discuss how your project group conducted peer-teaching for your scenario group. These sections (A
and B) should be supported by evidence, which may take the form of self-assessments, peer or
facilitator comments, or any other evidence that the group may have generated.
c.
Analyse your project groups performance as well as the contributions made by each member of
your project group. The analysis should be undertaken from the perspective of a relevant theoretical
model on teamwork (You may select a model from:
https://medprogram.med.unsw.edu.au/teamwork-group-projects Identify three strengths in the
approach your group adopted, and identify three ways in which you could improve the process if you
were to engage in a similar collaborative activity in the future. (This section (3c) will help you meet
the requirements for the generic Teamwork capability.)
The report should be a maximum of 2500 words. Include a component to address the generic Teamwork as
described above.
required).
Assessment criteria
Focus Capability 1: Self-Directed Learning and Critical Evaluation
Formulates a good range of tutorial questions that relate to the recommended capabilities. The questions
are accompanied by a brief discussion of the content that was relevant when formulating the model
answers (within report). This brief discussion outlines the relevant content areas, the significant links
between them, and the important concepts that should be understood in order to effectively answer the
questions. (1.6.1 Identifies questions and learning issues arising from scenario sessions and other
teaching activities. Engages in appropriate activities to address identified needs.)
Session 2: TP4 2015
Page 90
Provides detailed model answers, analyses common misconceptions and formulates appropriate feedback
(to be included within the appendix.) (1.6.1. Engages in appropriate activities to address identified
needs.)
Focus Capability 2: Teamwork

Develops appropriate methods of peer teaching and discusses the effectiveness of these methods. (1.5.1
Identifies different purposes of group work, analyses how well groups work)
Identifies strengths and areas for improvement. (1.5.1 Discusses differences in contribution styles and
identifies contributions in terms of task focused behaviour, group support behaviour, nonproductive
behaviour)
Provides evidence of helping the wider scenario group to better understand the relevant learning issues,
their inter-relationships, and how the selected learning issues can be applied to an alternate scenario. Uses
an appropriate method to gather this evidence. (1.5.3 Analyses and evaluates own roles and
contributions to group work using own observations and feedback from others)
In doing so, you could Identify strengths and areas for improvement, and discuss these in a constructive
manner. Please ensure that you refer to the Teamwork generic capability criteria and address these criteria
which include providing documentation of team meetings, evaluation of group process and reflection on
features that enhanced or impeded group process. Section 3c of the report requirements relates to meeting
the generic teamwork capability.
References
Teamwork for Group projects - Please refer to this webpage for resources to help you meet the
requirements for the generic Teamwork capability: https://medprogram.med.unsw.edu.au/teamworkgroup-projects
World Health Organization (2010). Topic 4: Being an effective team player. WHO Patient Safety Curriculum
Guide. http://www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf
172H
Glynn, L., Macfarlane, A., Kelly, M., Cantillon P. and Murphy, A. (2006). Helping each other to learn a
process evaluation of peer assisted learning. BMC Medical Education 6: 18.
Jaques, D. (2000). Learning in Groups (3rd ed.). London: Falmer/Kogan Page.
Johnson, D.W. and Johnson, R.T. (1994). Learning Together and Alone: Cooperative, Competitive and
Individualistic Learning (4th ed.). Boston: Allyn and Bacon.
Contact:
A discussion regarding this project is available through Moodle.

Session 2: TP4 2015
Page 91

AEA StudentGuide 15 Finalv2

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

AEA StudentGuide 15 Finalv2

Uploaded by

Copyright:

Available Formats

MFAC1525 Ageing & Endings A

Student Guide 2015

Session 2: TP4 2015

Ageing & Endings A Student Guide

Ageing & Endings A Student Guide

Welcome to Ageing and Endings A!

Aims of the course

Course changes for 2015

Ageing & Endings A Student Guide

Staff involved in the course

Prof. Ken Ashwell

Ageing and Endings Design and Implementation Group

Dr Barbara Ann Adelstein

Medicine Education and Student Office (MESO)

Scenario group session preparation

Attend the Plenary

Bone structure - watch video and review lecture notes

Bone remodelling pre-reading and presentation

Do QMP online tutorial and view videos

Attend the Plenary.

Bring anatomy lecture notes and textbook (hard or soft copy)

Attend the Plenary

Prepare for project presentations

Watch video on colorectal anatomy and do online quiz

Pain management presentation

Ageing & Endings A Student Guide

Scenario 1: Alma Jones Osteoporosis

Scenario Plenary 1: Alma Jones: Osteoporosis

Ageing & Endings A Student Guide

Scenario 1: Alma Jones Osteoporosis

Ageing & Endings A Student Guide

SGS 1: Introduction to the course and the scenario

Key concepts for the course

Ground rules, course assessment requirements.

Student resources needed for this session

Introductions and housekeeping

Review the scheduled learning activities

Explore and evaluate a public health program

Review the project and assignment options

Preparation for SGS 2

1. Introductions and housekeeping 10 mins

Ageing & Endings A Student Guide

Size of typical serve (g)

6. Explore and evaluate a public health program 30 mins

Ageing & Endings A Student Guide

7. Review the project and assignment options 10 mins

Bone structure and cells: https://www.youtube.com/watch?v=yFJ4iswRiu4

Ageing & Endings A Student Guide

SGS 2: Bone structure and development

Structure and development of bone

Understanding the structure of bone and its development

Battle of the Wits Quiz

Preparation for SGS 3

Ageing & Endings A Student Guide

Group 4: Joints and movement

Ageing & Endings A Student Guide

SGS 3: Bone remodelling

Physiological remodelling of bone

Group presentations on bone remodelling

Preparation for SGS 4 and session round up

1. Group presentations on bone remodelling 60 mins

Ageing & Endings A Student Guide

Group 3: Diagnosis and screening for osteoporosis:

SGS 4: Falls in the elderly