By I. Ressel. Andrew Jackson University. 2019.

The ester functions in glucopyranose pentaacetate undergo the typical ester reactions order cheapest terramycin. Ether formation When methyl a-D-glucopyranoside (an acetal) is treated with dimethyl sulphate in presence of aqueous sodium hydroxide buy 250mg terramycin amex, the methyl ethers of the alcohol functions are formed buy discount terramycin 250mg on line. The methyl ethers formed from monosacchar- ides are stable in bases and dilute acids 250mg terramycin free shipping. A solution of pure glucose has been recommended for use by subcutaneous injection as a restorative after severe operations, or as a nutritive in wasting diseases. Its use has also been recommended for rectal injection and by mouth in delayed chloroform poisoning. For coloured pills many dispensers prefer a mixture of equal weights of extract of gentian and liquid glucose. Liquid glucose is particularly suitable for the preparation of pills containing ferrous carbonate. It preserves the ferrous salt from oxidation, and will even reduce any ferric salt present. Conversely, it should not be used where such reduction is to be avoided, as in the preparation of pills containing cupric salts. Apart from the pharmaceutical or medicinal uses, glucose is also used in large quantities in the food and confectionery industries, often in the form of thick syrup. Fructose, another common monosaccharide found in fruits and honey, is more soluble in water than glucose and is also sweeter than glucose. It is used as a sweetener for diabetic patients, and in infusion for parenteral nutrition. Such a bond is called a 1,4 where two glucose units are linked between C-1 and C-4 via oxygen. The most common naturally occurring disaccharides are sucrose (table sugar) and lactose (milk sugar). While sucrose is derived from plants and is prepared commercially from sugar cane and sugar beet, lactose is found in the milk of animals. Other common disaccharides that are produced by breaking down polysaccharides include maltose (obtained from starch) and cellobiose (obtained from cellulose). Maltose and cellobiose Maltose is a disaccharide, composed of two units of glucose linked (a linkage) between C-1 of one and C-4 of the other via oxygen. For example, in maltose, since the ‘linkage’ is a, and is in between C-1 of one glucose and 0 C-4 of the other, the ‘linkage’ is called a 1,4. They react with Benedict’s and Fehling’s reagents, and also react with phenylhydrazine to yield the characteristic phenylosazone. If you have a closer look at the following structures of maltose and cellobiose, you will see that the left-hand glucose possesses an acetal link (glycosidic link) but the right-hand glucose still has the hemiacetal at C-10. The right-hand glucose can exist in an equilibrium of a and b anomers, and the open chain form. While maltose is the building block of the polysaccharide starch, cellobiose is the building block of another polysaccharide, cellulose. Malt consists of the grain of barley, Hordeum distichon (family Grami- neae), partially germinated and dried. Pharmaceutically, extract of malt is used as a vehicle for the administration of cod-liver oil, and the liquid extract is given with haemoglobin, extract of cascara and various salts. Lactose Lactose, found in milk and a major component of whey, is a disaccharide that is composed of a unit of glucose and a unit of galactose through a 6. Like maltose and cellobiose, lactose is a reducing sugar because of the presence of hemiacetal on the right-hand sugar (glucose). Therefore, it also undergoes similar reactions to those of cellobiose and maltose, and shows mutarotation. It is the second most widely used compound and is employed as a diluent, filler or binder in tablets, capsules and other oral product forms. As lactose is only 30 per cent as sweet as sugar it is used as a sugar supplement, and also in food and confectionery. Sucrose Sucrose is a disaccharide that is composed of a unit of glucose (acetal form) and a unit of fructose (ketal form) linked through C-1 of glucose and C-2 of 0 fructose, i. In sucrose, neither glucose nor fructose can exist in open chain form because of the formation of acetal and ketal as shown below. This phenomenon of sucrose is called the inversion of sucrose, and the resulting mixture is known as invert sugar, which is the main component of honey, and is sweeter than sucrose itself. Starch and cellulose are the two most important polysaccharides from biological as well as economical viewpoints. Starch Starch, an essential component of our diet, is a high molecular weight polymer of glucose where the monosaccharide (glucose) units are linked mainly by 1,4 -0 a-glycoside bonds, similar to maltose. Starch is obtained from wheat (Triticum sativum), rice (Oryza sativa)andmaize(Zea mays), all from the plant family Gramineae. Potato (Solanum tuberosum; family Solanaceae) and maranta (Maranta arundinacea; family Marantaceae) are also good sources of starch. Starch consists of two main components: amylose (insoluble in cold water) and amylopectin (soluble in cold water). Amylose, which accounts for about 20 per cent by weight of starch, has an average molecular weight 6 of over 10. It is a polymer of glucopyranose units linked together through a 1,4 -linkages0 in a linear chain. This is the colour reaction of iodine in starch, a confirmatory test for the presence of starch. Amylopectin contains branches (nonlinear), approximately one in every 20 to 25 glucose units. Starch soaks up secretions and helps to render injured parts less liable to bacterial infections. As a dusting powder for application to chafings and excoriations, it is used either alone or mixed with zinc oxide, boric acid and other similar substances. Like amylopectin, 0 0 glycogen contains a complex branching structure with both 1,4 and 1,6 links, but it is larger than amylopectin (up to 100 000 glucose units) and much more branched. It has one end glucose unit (where glucose can be added or released) for every 12 units and a branch in every six glucose units. Cellulose Cellulose, the most abundant natural organic polymer, consists of several thousands of D-glucose units linked by 1,4 -0 b-glycoside bonds as in cellobiose. Different cellulose molecules can then interact to form a large aggregate structure held together by hydrogen bonds. Nature uses cellulose mainly as a structural material to provide plants with strength and rigidity. Therefore, human digestive enzymes cannot hydro- lyze b-glycosidic links between glucose units. In human beings, starch (but not cellulose), is hydrolyzed enzymatically to produce glucose. While there is no food value in cellulose for humans, cellulose and its derivatives are commercially important. Cellulose is used as raw material for the manufacture of cellulose acetate, known commercially as acetate rayon, and cellulose nitrate, known as guncotton. Natrosol (hydroxyethylcellulose) is a nonionic water-soluble polymer that is extensively used as a thickener, 6. Natrosol is also used in cosmetic preparations as a thickening agent for shampoos, conditioners, liquid soaps and shaving creams. Carbohydrate antibiotics Antibiotics that contain one or more amino sugars within the molecule are called carbohydrate antibiotics. For exam- ple, gentamicin is composed of three different units: purpurosamine, 2-deoxystreptamine and garosamine. Therefore, human beings need an external supply of this vitamin, mainly from fresh vegetables and fruits. In many pharmaceutical preparations ascorbic acid is used as an antioxidant preservative. Ascorbic acid is highly susceptible to oxidation, and oxidized easily to dehydroas- corbic acid. Biologically these are important compounds as they are an integral part of cell membranes. The carbohydrates in the membrane are covalently bonded to proteins (glycoproteins) or with lipids (glycolipids).

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Al- though most children begin puberty between the ages of 10 and 12 discount 250mg terramycin with mastercard, it can start at any age from 8 to 16 purchase generic terramycin on-line. The most obvious determining factor is gender; on average buy terramycin from india, puberty arrives earlier for girls than boys buy generic terramycin 250mg on line. Compared to an overall age range of nine to 18 for menarche, the age difference for sisters averages only 13 months and for identical , less than three months. Body weight is a factor as well: puberty often begins earlier in heavier children of both sexes and later in thinner ones. The onset of menstruation, in particular, appears to be relat- ed to amounts of body fat. Girls with little body fat, es- pecially athletes, often start menstruating at a later- than-average age. Over the past 100 years, puberty has tended to begin increasingly early in both sexes (a phe- nomenon called the ). Herman-Giddens of University of North Carolina at Chapel Hill School of Public Health provided evidence that the average age of menarche was declining. Instead of occurring between the ages of 12 and 14, as is typical in the late 1990s, girls’ first menstrual periods commonly appeared be- tween the ages of 15 and 17 in the 19th century. Puber- ty in boys usually didn’t begin until the ages of 15 or 16 (in the late 18th and early 19th centuries, boy sopra- nos in their mid-to-late teens still sang in church least a year after menarche young women’s fertility lev- choirs). Explanations for this pattern have ranged from els are very low, and they are prone to spontaneous evolution to better health, especially as a consequence abortions if they do conceive. In boys, as in girls, the first outward sign of sexual An important aspect of puberty is the development maturation is often light-colored pubic hair around the of. The testes and scrotum bodies during this period, either because they feel they begin to grow, and the scrotum darkens, thickens, and are maturing too early or too late, or because they fail becomes pendulous. About a year after the testes begin to match the stereotyped ideals of attractiveness for to increase in size, the penis lengthens and widens, tak- their sex (i. Girls who mature early have a hard increases, and ejaculations—the male counterpart to time initially because they feel self-conscious and iso- menarche in girls—begin, occurring through nocturnal lated, but they adjust well and even gain in status once emission, masturbation, or sexual intercourse. Some research even sug- from one to three years until ejaculations contain enough gests that girls who mature early may ultimately be sperm for a boy to be really fertile. Those who are already tall and athletic grows and the vocal cords lengthen, his voice drops in junior high school feel better about themselves than (roughly an octave in pitch) and changes in quality. Researchers have though girls’ voices also become lower, the change is linked late physical maturation in boys to the develop- victim’s home. Rape is one of the most underreported crimes in the United States, due to the victim’s fear of With the rise of Nazi Germany, Rank, a Jew, emi- embarrassment, humiliation, or retaliation by the rapist. Teaching at the Penn- Estimates of the percentage of rapes reported to authori- sylvania School of Social Work, he adopted the nickname ties range from 10 to 50 percent. Because of the difficul- “Huck,” after his favorite American book, ty of obtaining a conviction, about two percent of all. Rank and his wife separated in rapists are convicted, and most serve approximately half 1934. A survey conducted in 1987 found that 57 percent of women who have been raped develop post-traumatic Rank has never received full credit for his contribu- disorder. These women may lose their appetite, tions to psychoanalysis and psychotherapy, primarily be- become easily startled, and suffer from headaches, cause of the attacks by Freudians. Many women have difficul- horred the Nazis, in 1939 the psychologist ty maintaining a normal life following a rape, and may labeled Rank’s “will therapy” a Nazi-style phi- repress the experience for an extended period before losophy. Over the past 20 years 1970s when it was resurrected by the psychologists feminist organizations have fought successfully to and , among others, and by writ- change public attitudes toward rape as well as treatment ers such as Anaïs Nin. Efforts have been made to increase the , with writings by Rank and his followers, was sensitivity of police and hospital personnel to rape vic- published biannually from 1966 until 1983. Today, women work, ,was finally published in police officers routinely investigate rape cases. Most states require physical evi- dence of recent sexual intercourse in which the victim most undergo a medical examination within 24 hours of the assault. In recent years, increased attention has been focused on “date” or “acquaintance” rape, a widespread phenom- ena that is particularly insidious because women who are victimized in this way are more likely to blame them- selves and are less likely to seek help or prosecute their Rape is essentially an act of and dominance. A 1987 study of acquaintance rape at 32 col- Although an estimated 15 to 40 percent of American lege campuses sponsored by magazine found that women are victims of rape or attempted rape, men are one in four women surveyed were victims of rape or at- raped as well. Women are more likely to be raped by tempted rape, that most rape victims knew their attack- someone they know; between 50 and 70 percent of all ers, and over half the assaults were date rapes. Only 27 rapes occur within the context of a romantic relationship, percent of the women identified themselves as rape vic- and more than half the time the assault takes place in the tims, and five percent reported the rapes to police. Of the Sigmund Freud mental health psychoanalysis character traits A projective personality assessment based on the subject’s reactions to a series of ten inkblot pictures. A group therapy approach in which clients act out their problems to gain new insights and achieve emotional catharsis. A powerful and destructive phenomenon wherein a person or group of people are blamed for what- ever is wrong. Too much or too little arousal can produce effect long-lasting behavioral changes. Thus, usefulness of encounter groups is limited to psychologi- appropriate degrees of sensory deprivation may actually cally healthy individuals, as the intense and honest na- have a therapeutic effect when arousal levels are too high. Sensory deprivation experiments of the 1950s have shown that human beings need environmental stimula- tion to function normally. In a classic early experiment, Separation anxiety emerges according to a develop- college students lay on a cot in a small, empty cubicle mental timetable during the second half year in human nearly 24 hours a day, leaving only to eat and use the infants. They wore translucent goggles that let in light maturation, rather than the onset of problem behaviors. The continuous hum kibbutzim, and Guatemalan Indians display quite similar of an air conditioner and U-shaped pillows placed patterns in their response to maternal separation, which around their heads blocked out auditory stimulation. They became disori- that the one-year-old is alerted by the absence of ented and had difficulty concentrating, and their perfor- the parent and tries to understand that discrete event. If it mance on problem-solving tests progressively deteriorat- fails, is created and the child cries. Although Cultural practices have an impact on separation anx- they were paid a generous sum for each day they partici- iety. Infants who remain in constant contact with their pated in the experiment, most subjects refused to contin- mothers may show an earlier onset of separation anxiety, ue past the second or third day. After they left the isola- and possibly more intense and longer periods of reactivi- tion chamber, the perceptions of many were temporarily ty. For example, Japanese infants who are tested in distorted, and their brain-wave patterns, which had ’s Strange Situation show more intense slowed down during the experiment, took several hours reactions to the separation, presumably as a result of cul- to return to. The intensity of the discomfort tural norms prescribing constant contact between mother these volunteers experienced helps explain why solitary and infant for the first several years of life. City of Hope National Medical the normal school experience by impeding the develop- Center. Systems that address personality as a combi- about 40% of children with Tourette syndrome often nation of qualities or dimensions are called trait theories. One was the distinction be- Tourette syndrome whose symptoms interfere with their tween personal dispositions, which are peculiar to a sin- ability to learn in a regular classroom gle individual, and common traits, which can be used for should become familiar with their children’s rights to an describing and comparing different people. While person- individualized education program under Public Law 94- al dispositions reflect the individual personality more ac- 142, the 1975 federal law aimed at insuring an adequate curately, one needs to use common traits to make any education for children with special needs. Allport also claimed that about seven central traits dominated each individual personality (he described Baton Rouge Tourette’s Support Group. Allport was the cardinal trait—a quality so intense that it [Juvenile] governs virtually all of a person’s activities (Mother personal management styles in many American corpo- rations have been linked to the increase in workplace violence, nearly one-fourth of which end in the perpe- trator’s suicide. One type of violence that has received increased at- The high incidence of violence in the United tention in recent years is domestic violence, a crime for States is of great concern to citizens, lawmakers, and which statistics are difficult to compile because it is so law enforcement agencies alike. Between 1960 and heavily underreported—only about one in 270 incidents 1991, violent crime in the U. Estimates of the and over 600,000 Americans are victimized by hand- percentage of women who have been physically abused gun crimes annually. Violent acts committed by juve- by a spouse or partner range from 20 percent to as high niles are of particular concern: the number of Ameri- as 50 percent. Young African American males are partic- by women of all ages, races, ethnic groups, and social ularly at risk for becoming either perpetrators or vic- classes.

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Dopamine receptor agonists bioavailability are improved by co-administration of decar- are started at a low dose that is gradually titrated upwards boxylase inhibitors buy terramycin 250 mg without a prescription. Ergot derivatives include bromocriptine cheap 250mg terramycin otc, lisuride cheap terramycin 250mg without a prescription, pergolide Drug interactions and cabergoline buy 250 mg terramycin overnight delivery. Other licensed dopamine agonists include Monoamine oxidase inhibitors can produce hypertension if pramipexole, ropinirole and rotigotine. The hypotensive actions of There is great individual variation in the efficacy of other drugs are potentiated by levodopa. The initial dose is gradually titrated upwards depending on response and adverse effects. Use • gastro-intestinal – nausea and vomiting, constipation or Amantadine has limited efficacy, but approximately 60% of diarrhoea; patients experience some benefit. The problems stem from its pharmacokinetics ade of both pathways of monoamine metabolism simultane- and from side effects of severe nausea and vomiting. The gastro- ously has the potential to enhance the effects of endogen- intestinal side effects can be controlled with domperidone. Apomorphine is started in hospital after pretreatment with domperidone for at least three days, and withholding other anti- parkinsonian treatment at night to provoke an ‘off’ attack. Apomorphine is that disease progression was slowed in patients treated with extensively hepatically metabolized and is given parenterally. Both isoen- availability of L-dopa centrally can be minimized by decreas- zymes metabolize dopamine. Amantadine and centrally active antimuscarinic agents potenti-ate the anti-parkinsonian effects of selegiline. Their main use is in patients with parkinsonism damage to upper motor neurone pathways following stroke or caused by antipsychotic agents. Physiotherapy, limited sur- Mechanism of action gical release procedures or local injection of botulinum toxin Non-selective muscarinic receptor antagonism is believed to (see below) all have a role to play. Drugs that reduce spasticity restore, in part, the balance between dopaminergic/cholinergic include diazepam, baclofen, tizanidine and dantrolene, but pathways in the striatum. Although spas- Key points ticity and flexor spasms may be diminished, sedating doses are Treatment of Parkinson’s disease often needed to produce this effect. Less sedation is produced than by equi-effective inhibitor (carbidopa or benserazide) or a dopamine doses of diazepam, but baclofen can cause vertigo, nausea and agonist (e. There is specialist with loss of effect at the end of the dose interval, and interest in chronic administration of low doses of baclofen to reduce ‘on–off’ motor fluctuations. It is used doses with a regrettable but inevitable increased intravenously to treat malignant hyperthermia and the neu- incidence of side effects, especially involuntary roleptic malignant syndrome, for both of which it is uniquely movements and psychosis. Botulinum A toxin is given by local injection into affected muscles, the injection site The γ-aminobutyric acid content in the basal ganglia is reduced being best localized by electromyography. It depletes neuronal become weak over a period of 2–20 days and recover over two terminals of dopamine and serotonin. It can cause severe dose- to four months as new axon terminals sprout and restore trans- related depression. The best long- there is no effective treatment for the dementia and other mani- term treatment plan has not yet been established. Electromyography has detected evidence of • The most common drug-induced movement disorders are systemic spread of the toxin, but generalized weakness does ‘extrapyramidal symptoms’ related to dopamine receptor not occur with standard doses. Metoclopramide, an anti-emetic, also Botulinum B toxin does not cross-react with neutralizing anti- blocks dopamine receptors and causes dystonias. Side effects include nau- • ‘Cerebellar’ ataxia – ethanol, phenytoin sea, vomiting, dizziness, vertigo, tachycardia, paraesthesia • Tremor and liver toxicity. These interact with postsynaptic nicotinic cholinoceptors at the neuromuscular junction. Clinically, the The precise stimulus for the production of the antireceptor anti- distinction may be difficult, but it is assisted by the edropho- bodies is not known, although since antigens in the thymus nium test. It tran- inhibitor of acetylcholinesterase, which produces a transient siently improves a myasthenic crisis and aggravates a cholinergic increase in muscle power in patients with myasthenia gravis. Because of its short duration of action, any deterioration of The initial drug therapy of myasthenia consists of oral anti- a cholinergic crisis is unlikely to have serious consequences, cholinesterase drugs, usually neostigmine. If the disease is although facilities for artificial ventilation must be available. In non-responsive or progressive, then thymectomy or immuno- this setting, it is important that the strength of essential (respira- suppressant therapy with glucocorticosteroids and azathioprine tory or bulbar) muscles be monitored using simple respiratory are needed. It reduces the number of circulating T-lym- Myasthenic crises may develop as a spontaneous deteriora- phocytes that are capable of assisting B-lymphocytes to produce tion in the natural history of the disease, or as a result of infection antibody, and a fall in antibody titre occurs after thymectomy, or surgery, or be exacerbated due to concomitant drug therapy albeit slowly. Corticosteroids and immunosuppressive drugs with the following agents: also reduce circulating T cells. Cholinesterase inhibitors enhance both muscarinic and nicotinic cholinergic effects. The Myasthenic crisis is treated with intramuscular neostigmine, former results in increased bronchial secretions, abdominal colic, repeated every 20 minutes with frequent edrophonium tests. Excessive muscarinic effects may be blocked by giving atropine or propantheline, but this increases the risk of over- Key points dosage and consequent cholinergic crisis. Myasthenia gravis Pyridostigmine has a more prolonged action than neostig- mine and it is seldom necessary to give it more frequently than • Auto-antibodies to nicotinic acetylcholine receptors four-hourly. The effective dose varies considerably between lead to increased receptor degradation and neuromuscular blockade. Azathioprine (see Chapter 50) has been used improves a myasthenic crisis while transiently either on its own or combined with glucocorticosteroids for its worsening a cholinergic crisis, allowing the appropriate ‘corticosteroid-sparing’ effect. Degeneration of cholin- eter of 2mm or less in normal lighting suggests overdose). The symptoms These findings led to pharmacological attempts to augment of Alzheimer’s disease are progressive memory impairment the cholinergic system by means of cholinesterase inhibitors. Ultimately, this leads to major cholinesterase inhibitors that are licensed for the treatment of behavioural and functional disability. Regular indicated in demented patients for symptoms of psychosis review through Mini-Mental State Examination with assessment or agitation but their use is associated with an increased risk of global, functional and behavioural condition of the patient is of stroke. Adverse effects Case history With all three drugs, adverse effects are mainly a consequence A 21-year-old woman was treated with an anti-emetic of the cholinomimetic mechanism of action and are usually mild because of nausea and vomiting secondary to viral and transient. She received an initial intramuscular dose of Fatigue, dizziness, dyspepsia, urinary problems and syncope 10mg of metoclopromide and then continued on oral have been reported. Careful dose titration can improve toler- metoclopramide 10mg three times a day, which relieved her nausea and vomiting. In overdose, a cholinergic crisis may develop including into the local Accident and Emergency Department severe nausea, vomiting, abdominal pain, salivation, lacrima- because her husband thought she was having an epileptic tion, urination, defaecation, sweating, bradycardia, hypoten- fit. Her arms and feet were twitching, her eyes were devi- sion, collapse, convulsions and respiratory depression. In ated to the left and her neck was twisted, but she opened addition to supportive treatment, atropine should be admin- her mouth and tried to answer questions. Question What is the diagnosis here and what is the most appropri- Drug interactions ate and diagnostic acute drug treatment? Theoretically, donepezil might interact with a number of Answer other drugs that are metabolized by cytochrome P450, but at Her posture, dystonia and head and ocular problems all point to a major dystonia with oculogyric crisis, almost cer- present there is no clinical evidence that this is important. In more severe cases, the treatment of choice is intravenous benztropine or procyclidine (anticholinergic agents), and further doses may be required, given orally. Key points An alternative, equi-effective but less satisfactory therapy Alzheimer’s disease because it is not diagnostic is intravenous diazepam. Febrile seizures are a distinct problem and are discussed at the end of this chapter. Mechanisms of action of anticonvulsants • The action of anticonvulsants is poorly understood. Key points • They cause blockade of repetitive discharges at a concentration that does not block normal impulse • Epilepsy affects 0. These agents are not all Before treatment is prescribed, the following questions sedative, but selectively block repetitive discharges at concen- should be asked: trations below those that block normal impulse conduction. Carbamazepine and phenytoin prolong the inactivated state of • Are the fits truly epileptic and not due to some other the sodium channel and reduce the likelihood of repetitive disorder (e. Consequently, normal cerebral activity, which • Is the epilepsy caused by a condition that requires is associated with relatively low action potential frequencies, is treatment in its own right (e. This ideal does not exist (the British National Formulary currently lists 23 anti-epileptic drugs), Generalized seizures and the choice of drug depends on the balance between effi- Primary (tonic–clonic) Valproate Clonazepam/ cacy and toxicity and the type of epilepsy being treated.

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If with business needs; working individually without a career plan discount terramycin 250 mg without prescription, it may be worth using such an example as a guide cheap 250 mg terramycin mastercard. The appraisal will cover many more areas than collating a portable record of progress and training and development needs discount terramycin 250 mg amex, for example per- achievement; formance output and relationships purchase genuine terramycin on-line, yet ultimately outcomes from appraisal will focus around the increasing awareness of potential career options; careers plan and what has to be done to achieve agreed goals. The training cycle remains the same, analysing strengths and weaknesses; and the five categories listed under induction may also be used to cover more focused training needs. Appraisal is an opportunity to record and assess focusing on development needs and career ambi- support and performance of the appraiser, other tions. The strict regulation A personal ‘syllabus’ will develop through fre- extends to matters concerning training and devel- quent appraisals leading to a continual personal opment, and the majority of disciplines will find development programme. When this begins to themselves governed by formal guidelines and include acquired further qualifications and for- legal requirements for the quality and quantity of mally evaluated course work, it may be called a training before and during the specific function. Most of undertake a professional and ethical obligation to the larger sponsor companies will run consolidated remain up to datewith best practice standards in the in-house courses covering a vast array of topics role that they perform. In smaller companies and as individuals, such ment in the pharmaceutical industry must be in-house programmes may not be available. A greater spectrum of The responsibility for keeping the training logs training experience may give greater value to a of staff vary from company to company, being held personal portfolio and offer a wider outlook of either by the human resources or training depart- the bigger picture. The marketplace offering com- ments or by the manager of the department to mercial courses to support any of the training needs which the individual belongs. However, it is for all of the disciplines within pharmaceutical recommended that each individual keeps a copy medicine is huge. It is important to be able to verify the effec- when applying to become a delegate. The simplest As has been highlighted, networking in the form of record, which details title, date and atten- industry is essential. Training may be competitive dees, does not inform an inspector, of any kind, between the commercial companies themselves, whether the training was of value or not. Human comparing the training data against the actual per- resources or heads of specific departments are good formance changes at appraisal. The most effective viewed as purely a top-level assessment and can commercial training companies are often those that raise more questions than it answers. It is recom- can tailor their training material to the needs of the mended to introduce a direct competency measure- trainees, and this material can be customized to ment to the evaluation of training. Here, a manager, specific sponsor company requirements when a coach or trainer will identify the training need prior group or team is involved. Clearly, the best source to training, and through witnessing, the trainees of specific training comes from the professional ‘put into practice’ what they have learnt, be able bodies supporting pharmaceutical medicine. In the to verify through dated signature the success or majority of cases, their primary objective is educa- failure of the training. It is important, however, tion based in order to maintain the highest possible that the training records are not made too complex, standards for their profession. The syllabus in pharmaceutical ing to the harmonization of existing postgraduate medicine covers medicines regulations, clinical courses in pharmaceutical medicine and promoting pharmacology, statistics and data management, mutual recognition of equivalent educational qua- clinical development, healthcare marketplace, lifications between countries. Since pharmaceutical medicine in United Kingdom (2), that time several similar courses have been founded Switzerland, Belgium, Spain (2) and Sweden. Although there are national variations, to under- take training where there is an outcome by exam- ination to obtain a diploma or degree, doctors must United Kingdom be registered in their country of medical qualifica- tion, must have undertaken a prescribed number of The Diploma in Pharmaceutical Medicine was years of approved clinical training prior to taking a established in 1976 by the three Royal Colleges post in pharmaceutical medicine and must have of Physicians of the United Kingdom. This is a 2-year part-time resi- ences and local academic standards and practices dentialstructuredtrainingprogrammeforregistered have induced major differences in the structure of physicians consisting of 10 modules, five per year; courses and the techniques of assessment andexam- each module lasts three days, and the full course ination. This is a competency-based in-work pro- ments in pharmaceutical companies, clinical gramme over four years which incorporates the research institutes and hospitals, official institu- Diploma in Pharmaceutical Medicine as the speci- tions and development departments in clinical ality knowledge base and six practical modules – research organizations. A generic module provides interpersonal is recognized by the Faculty of Pharmaceutical and management skills and working to the princi- Medicine as equivalent to that in the United ples of Good Pharmaceutical Medical Practice, Kingdom. The Each of the modules takes one full week every outcome is the Certificate of Completion of month between November and June, leading to Training, a recognised European credential of 280 hours of teaching. In the first year, all courses are at the awarded the Diploma in Pharmaceutical Medicine, University of Lyon, but in the second year, students which is recognized by the Belgian College of move around the various participating universities. Pharmaceutical medicine, established in 2000 by To obtain the diploma, the candidate sits written two Belgian Royal Academies of Medicine. Holders are added to a specialist register held by The total number of teaching hours is estimated the Belgian College of Pharmaceutical Medicine. The diploma is recognised by the Faculty of Pharmaceutical Medicine (London) as being equivalent to that of the United Kingdom. Spain The University of Barcelona offers a 2-year non- Ireland residential course consisting of 14 modules between 4-30 hours depending on the subject. Written examina- acceptance for pharmaceutical medicine as a spe- tions are conducted twice a year. This was accepted by the The University of Madrid offers a 2-year non- Irish Medical Council in 2004, and the medial residential course which consists of 14 modules speciality was approved by the Ministry of Health from October to June and totalling 300 hours of in 2005. Successful candidates training requirements for specialist accreditation receive a Diploma in Pharmaceutical Medicine. There is an international teaching faculty per month, representing a total of 176 hours of involving many from the United Kingdom, Swe- teaching. The course is at variance each module, and only those students who have with other courses in pharmaceutical medicine in passed the 11 assessments and have attended 100% that during the first year, all students attend three of the course are allowed to submit a dissertation of residential seminars of 3-week duration, represent- 20 000 words at the end of the course. There are practical rotations through Sweden pharmaceutical industry departments in the fourth semester. There is a 2-year diploma course in pharmaceutical medicine given at the Karolinska Institute and the Medical Products Agency, Stockholm, organized Argentina for pharmaceutical physicians in conjunction with the Swedish Board of Pharmaceutical Medicine. The University of Buenos Aires offers a postgrad- uate education programme in pharmaceutical med- icine, comprising 420 teaching hours and 240 Germany practice hours. Since 2005, the University of Essen-Duisburg The Federal University of Sao Paulo offers a has offered a 2-year course leading to a Master of postgraduate course in pharmaceutical medicine Science in pharmaceutical medicine. The course comprising 200 teaching hours and 160 practice has 450 hours of teaching in 18 modules and a hours. The last six months are needed for preparation of a thesis, its presentation and oral examination. Acknowledgements Although only recently available, this course has longer heritage, having being transferred from the The authors wish to thank Gareth Hayes, Dr University of Witten-Herdecke, which since 1997 Ibrahim Farr and Drs Herman Lahon and Juan offered a course leading to a Diploma in Pharma- Lahuerta of the Council for Education in Pharma- ceutical Medicine. Italy In pharmaceutical medicine, efforts are being References made to establish a diploma course at the Univer- sity of Pisa supported by the Italian Association of Centre for Medicines Research. Most major pharma- lated industry where many of the activities and ceutical firms have always had varying degrees of tasks performed by company staff are defined by in-house education and training for staff, supple- regulations and guidelines issued by international mented (as appropriate) by external workshops, regulatory authorities. This knowledge and clinical staff to conduct world-class clinical skill usually need to be provided by sponsors to all research. Traditional approaches tend edge and competencies needed to plan, conduct to address the training needs of individuals based and report clinical research in a regulated environ- on their job descriptions. Each competency is described along with the sponsor company, a monitor will receive training knowledge and skills a sponsor’s representative on how to monitor a clinical trial and a physician would need to be successful in completing the task. In this traditional education and training model, the required tasks are functionally defined. The moni- tor may not learn much about preparing protocols General clinical competencies and the physician may not learn much about monitoring. However, each may be intimately Understanding the drug development process involved in both tasks. Before new investiga- primary tasks of clinical research and good clin- tional products can be given to the public, extensive ical practice can be described rather precisely. Staff who will be responsible for the clin- what activities are needed to accomplish these ical portion of investigational product’s tasks, one can then ask what knowledge and skills development need to have an understanding of are needed by staff for the tasks and, finally, what the work that has been undertaken to progress the education and training should be provided to com- compound through to the clinical phases. Only research and often will expect the sponsor’s repre- when the tasks and activities are fully defined is it sentative to be able to discuss the total background necessary to ask who is going to do it and how on the investigational product. This includes understanding the vision, mission In the example provided above, it is useful for the and objectives of the sponsor. Most sponsors have a physician to have a fundamental knowledge of the company-specific clinical development strategy monitoring process even though he or she will not and product development system. The physician may, how- new to the industry should understand the strategy ever, be supervising the monitors. It is appropriate and function of the major departments comprising for the monitor to receive advanced training in the the development process, as well as understanding requirements of monitoring as this is one of their the decision-making approach of the sponsor’s major functions.

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