Download Cardiovascular Course Anita Soni

Cardiovascular
Course
Anita Soni
MD FRCPC Cardiology
June 10, 2013
UGME CV Course Committee
Course Leader: Anita Soni
Administrative Assistant: Kathy van der Vis
Basic Sciences:
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Anatomy: Sabine Hombach-Klonisch
Embryology: Mark Torchia
Physiology: Ian Dixon
Pharmacology: Don Smyth
Cardiology:
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Heart Failure/nuclear: Francisco Cordova
IHD/hemodynamics: John Ducas
Arrhythmia: Kevin Wolfe
Valvular Heart Disease/other: Anita Soni
ECG/Imaging- Davinder Jassal
Preventative/Rehab- Thang Nyugen
Related Medical Disciplines:
 Intensive Care: Alan Schaffer
 Vascular Surgery: April Boyd
 Cardiac Surgery: Ed Pascoe
Longitudinal Themes
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Generalism: Travis Minish
Pathology: Gabor Fischer
Infectious Diseases: George Zhanel
Genetics: Sandra Marles
Pediatrics: Reeni Soni
Radiology: Iain Kirkpatrick
Geriatrics: Colette Seifer
Longitudinal Courses:
 Community Health: Sharon MacDonald
 Clinical Skills: Karen Klym
 Indigenous Health: Barry Lavallee
Resident:
 Robin Ducas (PGY 5 Cardiology)
Student:
 William Liang (CV course rep)
CuRe Preclerkship M0, 1/2: Human Biology , Health and Disease
Y1
 Human Biology and Health
wks.days ( w. 2 days eval )
M0 • FOUNDATION of MEDICINE
M1 1. Blood & Immunology I (+ Skin I)
2. CV I & Resp (+ ET) I
3. Neurobiology I(Psych, Neuro + Opth)
4. Musculoskeletal I
5. Endocrine I & OBS/Gyn I
6. GI/ Nutrition I & Urinary system I
TOTAL
CuReX DRAFT 3
March 11, 2013
Approximate dates
4 ---- 2014 Aug 25 - Sept 19
3------------ Sept 22 - Oct 10
5 ------------ Oct 13 - Nov 14
4.6 --------- Nov 17 - Dec 17… Dec break
2------2015 Jan 5 - Jan 16
4------------- Jan 19 - Feb 13
4------------- Feb 17 - Mar 13
26.6
……………….Mar 16 - 20………Reading week
M2  Health and Disease
1. Intro to ID/Intro Oncology
2. Blood & Immunology (+ autoimmune diseases) 2
3. CV 2
Y2
4.
5.
6.
7.
8.
9.
10.
Resp + ET 2
Endocrine 2
OBS/Gyn 2
GI & Nutrition 2
Urinary system 2
Neurobiology 2 (Psych, Neuro, Opth)
Musculoskeletal 2 (+Skin 2)
M3  Consolidation
2-------------Mar 23 - April 3
5
3-------------Apri 6 - April 24
4-------------Apri 27 - May 22
-----------May 25- 29 …………. Rural week
4--------------Aug 24 - Sept 18
3--------------Sept 21 - Oct 9
3--------------Oct 12 - Oct 30
3 -------------Nov 2 - Nov 20
3 +3d------- -Nov 23 - Dec 17…… Dec break
6 -----2016- Jan 4 - Feb 12
4--------------Feb 18 - Mar11
----------------Mar 14 - 18 ……. Reading week
10-------------Mar 21 - May 27
3
Goals:
①Create Outline for the CV course:
 Specific topics  objectives content format
 Review current course
 IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT)
- compare to other medical schools/review MCC objectives
 Ensure related medical disciplines and longitudinal
themes are represented
Goals:
② Organization and Integration:
 Dividing into Module 1 & Module 2
- Integration of longitudinal courses to optimize learning
- Integration of longitudinal themes- where they fit in
 Consolidation
 Clerkship (academic ½ day)
Goals:
①Create Outline for the CV course:
 Specific topics  objectives content format
 Review current course
 IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT)
 compare to other medical schools/review MCC objectives
 Ensure related medical disciplines and longitudinal
themes are represented
Current CV Course Objective (OPAL)
CV.1 Describe the scope and burden of illness of cardiovascular disease in our
community.
CV.2 Explain normal anatomy, physiology, and pathology of the cardiovascular system.
CV.3 Explain the abnormal anatomy, physiology, and pathology in cardiovascular
disease: including ischemic heart disease, heart failure, rhythm disorders, valvular heart
diseases, pericardial/myocardial disorders, shock, peripheral vascular diseases, thoracic
aortic disease, hypertension, endocarditis and congenital heart disease.
CV.4 Perform a cardiovascular history and physical examination in patients with
cardiovascular disease.
CV.5 Evaluate the clinical presentations of cardiovascular diseases, including the workup of chest pain syndromes, shortness of breath, palpitations and syncope.
CV.6 Describe primary prevention, risk factors and risk factor modification for
cardiovascular diseases.
CV.7 Discuss and implement the clinical tools and investigations available for the
evaluation of cardiac patients. Have an approach to ECG interpretation.
CV.8 Describe the treatment options of cardiovascular diseases, both acute and chronic
Current Cardiovascular Course
Intro,
Reviews &
Community
Health
Aorta &
PVD
Instructional
Embryology
tests
Anatomy
Physiology
Infections
Shock
/Vascular and
Autonomic
Drugs
EKG
Cardiovascular
Course
Genetics/
Molecular
Arrhythmia
HTN
Pericardial and
Cardiomyopathy
Congenital
&
Pediatrics Heart
Failure
Lipids
Imaging
Ischemic
Heart
Valvular Disease
Heart
Disease
Current Cardiovascular Course
Intro,
Reviews &
Community
Health
Aorta &
PVD
Instructional
Embryology
tests
Anatomy
Physiology
Infections
Shock
/Vascular and
Autonomic
Drugs
EKG
Cardiovascular
Course
Genetics/
Molecular
Arrhythmia
HTN
Pericardial and
Cardiomyopathy
Congenital
&
Pediatrics Heart
Failure
Lipids
Imaging
Ischemic
Heart
Valvular Disease
Heart
Disease
Current Cardiovascular Course
Intro,
Reviews &
Community
Health
Aorta &
PVD
Instructional
Embryology
tests
Anatomy
Physiology
Infections
Shock
/Vascular and
Autonomic
Drugs
EKG
Cardiovascular
Course
Genetics/
Molecular
Arrhythmia
HTN
Pericardial and
Cardiomyopathy
Congenital
&
Pediatrics Heart
Failure
Lipids
Imaging
Ischemic
Heart
Valvular Disease
Heart
Disease
Course
ID
CV001
CV059
CV041
CV002
CV003
CV008
CV041
CV044
CV048
CV014
CV004
CV010
CV011
CV013
CV015
CV017
CV025
CV027
CV029
CV030
CV019
CV020
CV058
CV045
CV023
CV022
CV024
CV026
CV059
CV033
CV034
CV037
CV038
CV016
CV078
CV079
CV080
Topic
Introduction to Cardiovascular
Mid Term Review
Cardiovascular Review
Anatomy of the Heart I
Anatomy of the Heart & Mediastinum and Thorax 1
Anatomy of the Heart II
CV Anatomy Review - Combined with RS 80
Development of the Heart
Development of the Heart and Lung
Autonomic Nervous System
Cardiovascular Physiology
Blood Pressure Regulation
Regulation of Cardiac Output and Venous Return
Hemodynamics 1
Hemodynamics 2
Cardiac Pathology: Consequences of Abnormal Hemodynamics
Cardiac Cycle
Cardiac Indices
Cardiac Performance
Abnormalities in Cardiac Performance
Excitation - Contraction Coupling
Cardiac Electrical Properties
Exercise Physiology and Stress Testing
Cardiovascular Physiology of Aging
Introduction to ECG 1
Introduction to ECG 2
ECG Interpretation 1
ECG Interpretation 2
ECG in IHD
Arrhythmias I
Arrhythmias II
Arrhythmias III
Arrhythmias IV
Hypertension I
Hypertension II
Hypertension III
Hypertension IV
Type
ID
Duration
L
IT
T
L
GLP
GLP
GLP
L
A/GLP
L
L
L
L
A
T
A
L
L
L
L
L
L
L
T
L
L
T
T
T
L
L
L
T
L
L
L
A
1
1
2
1
1
2
1
2
2
2
2
1
2
2
2
1
2
1
2
1
2
2
2
1
2
1
2
2
1
2
1
2
2
1
1
1
1
Dept
ID
IN-CV
IN-CV
IN-CV
AN
AN
AN
AN
AN
AN
PC
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
PA
IN-CV
IN-CV
PC
PC
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
PC
PC
IN-CV
IN-CV
IN-CV
IN-CV
IN-CV
Session
Leader
Anita Soni
Anita Soni
Anita Soni
Sabine Hombach-Klonisch
Sabine Hombach-Klonisch
Sabine Hombach-Klonisch
Sabine Hombach-Klonisch
Mark Torchia
Mark Torchia
Don Smyth
Rohit Singal
Bojan Paunovic
Bojan Paunovic
Bojan Paunovic
Bojan Paunovic
Gabor Fischer
Andrew Morris
Malek Kass
Ian Dixon
Ian Dixon
Larry Hryshko
Ali Khadem
Ivan Barac
Colette Seifer
Nasir Shaikh
Davinder Jassal
Nasir Shaikh
Nasir Shaikh
Nasir Shaikh
Kevin Wolfe
Kevin Wolfe
Kevin Wolfe
Kevin Wolfe
Brian Penner
Brian Penner
Brian Penner
Brian Penner
Introduction, Reviews, Instrucitonal Tests
Anatomy
Embryology
Physiology
ECG
Arrhythmias
Hypertension
CV057
CV064
CV063
CV005
CV061
CV058
CV051
CV052
CV056
CV066
CV059
CV059
CV059
CV062
CV062
CV062
CV062
CV062
CV062
CV081
CV053
CV040
CV040
CV040
CV040
CV042
CV040
CV
CV046
CV043
CV021
CV028
CV031
CV041
CV045
CV032
CV039
CV041
CV059
CV041
Lipid Metabolism and IHD I
Lipid Metabolism and IHD II
Lipid Metabolism and IHD III
Cardiac Pathology: Atherosclerosis
Cardiac Pathology: IHD
Exercise Physiology and Stress Testing
Acute Coronary Syndromes
Chronic IHD
Revascularization in IHD
IHD I
ECG in IHD
IHD II
Cardiac Pathology: Valvular Heart Disease
Valvular Heart Disease I
Valvular Heart Disease II
Valvular Heart Disease III
Cardiac Pathology: Pulmonary Vascular Disease and Cor Pulmonale
Cardiac Pathology: Heart Failure
Heart Failure & Therapy I
Heart Failure & Therapy II
Heart Failure & Therapy III
Heart Failure & Therapy IV
Congenital Heart Disease I
Acquired Conditions in Pediatric Heart Disease
Congenital Heart Disease II
Congenital Heart Disease III
Pericarditis & Cardiomyopathies
Genetic Aspects of Cardiomyopathy
Molecular Aspects of Cardiac Disease
Shock I
Shock II
Vascular and Autonomic Drugs I
Vascular and Autonomic Drugs II
Vascular and Autonomic Drugs III
Cardiac Infections
Diseases of the Thoracic Aorta
Vascular Disease I
Vascular Disease II
Prevention of Vascular Disease
Appl yi ng Communi ty Hea l th Concepts to Res p a nd Ca rdi ova s cul a r Di s ea s e 1
L
L
T
L
LP
L
L
L
L
A
T
T
T
A
T
T
L
L
L
L
L
T
A
L
L
T
L
L
L
L
T
L
L
T
L
L
L
T
L
A
1
1
2
2
1
2
2
2
1
1
1
2
1
1
3
2
1
1
2
1
1
2
1
1
2
2
1
1
1
1
2
1
1
2
1
1
2
1
1
0
IN-CV David Mymin
IN-CV David Mymin
IN-CV David Mymin
PA
Gabor Fischer
PA
Gabor Fischer
IN-CV Ivan Barac
IN-CV Kunal Minhas
IN-CV John Ducas
SG
Kunal Minhas
IN-CV Kunal Minhas
IN-CV Nasir Shaikh
IN-CV Kunal Minhas
PA
Gabor Fischer
IN-CV Anita Soni
IN-CV, SGAnita Soni/Rizwan Manji
IN-CV Anita Soni
PA
Gabor Fischer
PA
Gabor Fischer
IN-CV Shelley Zieroth
PC
Anita Soni
PC
Anita Soni
IN-CV Shelley Zieroth
PD
Reeni Soni
PD
Reeni Soni
PD
Reeni Soni
PD
Reeni Soni
IN-CV John Ducas
BC GN-GNAb Chudley
IN-CV Davinder Jassal
IN-CV Rizwan Manji
IN-CV Rizwan Manji
PC
Don Smyth
PC
Don Smyth
PC
Don Smyth
MM
Fred Aoki
SG
Ed Pascoe
SG
Josh Koulack
SG
April Boyd
CH
Sharon Macdonald
CH
Sharon Macdonald
Lipids
Ischemic Heart Disease
Valvular Heart Disease
Heart Failure
Congenital & Pediatric Heart Disease
Pericardial Disese & Cardiomyopathies
Genetics-Cardiomyopathies
Molecular Aspects
Shock/Vasclar & Autonomic Drugs
Infections
Aorta/Peripheral Vascular Disease (Surgery)
Community Health
Clinical Skills
1. Intro session- 2 hours of
demonstration with 5
groups- rotating through 5
stations:
1.
2.
3.
4.
5.
History
JVP
BP
Heart Sounds
Peripheral exam
2. Three 2 hour small group
sessions (5-6 students)
with a cardiologist using
real patients on ward
Gaps
• Preventative medicine- primary prevention –
cover HTN and Lipids directly, but no specific
lecture formally dedicated to smoking, diet, DM,
obesity (from a clinical perspective)
• Diet and nutrition (ie. Mediterranean diet).
• Cardiac rehabilitation
• Presyncope / syncope
• Pericardial disease and cardiomyopathies should
be separated
• Indigenous health
• Interprofessionalism/ multidisciplinary care
Overlap- relevant vs redundant
• Physiology section- combination of lecturers from different
fields leading to some redundancy. Also, some ICU oriented
sessions with question of relevancy
• IHD- some redundancy; review content relevancy
• Autonomic nervous system- how much to cover with new
curriculum (no longer being taught prior to course)
• Lipids- also covered in Endocrine ?combine
• pulmonary HTN/cor pulmonale- one pathology lecture
(combined with resp), not covered in CV otherwise
• Pathology- ?some redundancy based on student evaluations
• Anticoagulants/antiplatelet drugs- overlap with heme?
• Shock- cover all types of shock ?relevant / ensure not
redundant
Goals:
② Organization and Integration:
 Dividing into Module 1 & Module 2
- Integration of longitudinal courses to optimize learning
- Integration of longitudinal themes- where they fit in
 Consolidation
 Clerkship (academic ½ day)
Module 1
Positive Aspects:
 Combined with Resp- ideal!
Integrate anatomy,
embyrology, and some
imaging (ie. CXR).
 Number of lecturers can be
limited:
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Course leader: intro, mid and
final test/review, diagnostic
testing/imaging, ECG (may
need one more cardiologist).
1 for Anatomy
1 for Embryology
2-3 for physiology
1 for pharmacology (also
some physiology)
1 radiologist
Module 1
Challenges:
 Ensuring enough baseline
knowledge to understand
pharmacology/drugs (ie.
autonomic nervous system,
heme / nephro background)
 Challenge to teach
diagnostic testing/imaging,
ECG and drugs without
clinical context, but will be
spiraling with M2.
 Integration into longitudinal
courses (?what topics to
cover)
 Timing of M1 is during 2 of
the most popular Cardiology
Conferences
Module 1
Consider?
 Pathology: in CV, pathology
lectures presently go though
pathological processes (ie.
atherosclerosis, or LV systolic
dysfunction), from a cellular
level. Introduces disease
states at a very basic level (ie.
IHD, CHF). It may be okay to
demonstrate some of these
abnormal processes (also
taught in physiology section as
it differs form normal
processes) in M1. This would
serve to introduce disease
states that will be unavoidably
discussed in diagnostic testing,
imaging, pharmacology and
clinical skills.
 Can shock/vascular &
autonomic drugs be taught in
M1- also serves as an intro into
disease states as above
Module 2
Positive Aspects:
 Excellent opportunity for
optimal integration with
longitudinal courses- would
like CV to be involved with
these sessions- (see later
slide) though also need to
consider resources with
tutors
 ‘Spiral’ curriculum- review
diagnostic
tests/imaging/ECG/drug
treatment -now under each
disease entity after being
taught in M1 first.
Module 2
Challenges:
 A lot of material to cover, only
appropriate in M2 (not M1)
 Difficult to go only theme
based (ie. approach to
dyspnea) without background
of disease first, and without
being paired with respirology
 Some topics better to be
theme based (ie. syncope)where to fit in?
 No time for
integration/unknown patient
case (except at final review
session)- unless move
pathology/shock to M1
 Very tight timing with 19
teaching days, and new
material on week of exam
(more ideal to combine with
Respirology also for resource
allocation)
Module 2
Challenges:
 Clinical skills- do not want to
compromise this section at all,
as it is the strongest part of
the current course:
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very very challenging in this
format of 4 weeks. Initially
allotted 4 hours 2x/ week.
This is impossible.
Intro session (one lecture,
one rotating stations), then
leaves 3 weeks (one session
per week per student).
To keep status quo: even if
given flexibility (2 hour time
slots, once per day), would
mean 4 groups (5-6 students
per group) per day, 5 days
per week (each group gets a
2 hour session), and repeat
next 2 weeks.
Timing/location- 8am best;
predominantly at SBGHneed to consider travel time.
Patient fatigue- Cardio ward
Resources- same tutor per
group; and also with
teaching in the am hours
Module 2
Challenges:
 There will be more lecturers
than what is perceived as
ideal:
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Course leader: intro, mid
and final test/review
ECG review
Arrhythmia
HTN
Dyslipidemia
IHD
HF
Valvular heart disease
Pericardial disease
Cardiomyopathies
Genetic
Molecular aspects
ID
Shock
Autonomic Drugs
Vascular
Pediatrics/Congenital
**Cardiologist-based topics
Longitudinal Courses:
Considerations:
 Clinical skills- extreme challenge
want to maintain current format
 Incorporating ‘theme-based’
approach into clinical reasoning.
 Ideal to have CV involvement:
ie- go through case from H & P,
to ECG, to diagnostic imaging
(include angiographic & echo
images or reports) and
treatment.
 Expand community health
 Professionalism:
 can we incorporate a
multidisciplinary session into
professionalism: include clinical
psychology, rehab, etc..
 ?transplant case-ethical issues
 Incorporate indigenous health topics
specific to CV
Longitudinal Themes
Considerations:
- Most themes well integrated into M1 and M2
- consider interprofessional care case- ?into professionalism course
- many are not specific to CV- fit into TTC/JC/SC/TTR portions
Composite Clinical Presentations CP4* UGME Sept 2012
SYMPTOMS & SIGNS
DRAFTV6
ABNORMAL LABS
HEALTH CONDITIONS
1 abdominal mass
2 abd pain: acute & chronic
3 allergic reactions
4 anxiety
34 hemoptysis
35 hirsutism
36 hoarse voice
37 impotence
38 incontinence
66 acidosis
67 alkalosis
68 hemoglobin disorders
69 calcium/phopshate/magnesium
99 ADHD spectrum
100 adrenal disorders
101 arthritis
102 CVD
103 cirrhosis
5 ascites
6 blunt trauma
7 burns
39 jaundice
40 joint pain-acute & chronic
41 low back pain
70
71 coagulation abnormalities
72 creatinine:acute & chronic
8 bleeding
42 lymphadenopathy
73
107 eating disorders
9
43 neck mass/thyroid
CXR abnormalities
74 lipid abnormality
104 CNS infections
105 diabetes
106 Drug OD
44 pain syndrome
75 leukocyte disorders
109 HIV/AIDS
11 constipation
12 cough- acute & chronic
45
46 pruritus
76 liver enzymes/function
77 potassium abnormalities
110
111 infertiltiy
13
14 delirium
15 dementia
16 diarrhea- acute & chronic
47 red eye
48 paralysis
49 pelvic pain/mass
50 seizures
78 platelet disorders
79 pulmonary function tests
80 sodium abnormalities
81 urinalysis abnormalities
112 kidney disease-chronic
113 lung disease-chronic
114 malnutrition
115 menses/menopause
17 diplopia
51 skin growths
18 dysphagia
52 skin rashes
82
117 multiple sclerosis
53 sleep disorders
54 somnolence
55 sore throat
84 Contraception
85 Culture
118 osteoprosis
119 pediatric emergencies
120 palliative care
86 WHO Determinants of Health
121 pituitary disorders
57 tendon rupture
58 testicular swelling/pain/mass
59 tinnitus
60 vomiting
61 vision loss acute&chronic
62 weakness
87 developmental pediatric delay
88 Disabilities
89 neglect/abusive relationship or behavior
90 educational level
91 elderly/frail
92 environmental health
122 pregnancy/complications
123 psychosis
124 suicidal behavior
125 shock/resuscitation
126 sports injuries
127 STI
63 wheezing- acute & chronic
93 infectious epidemic/prevention
128
98
133
cardiac murmurs
10 chest pain
cyanosis
dyspnea-acute & chronic
19
20 dysuria/UTI
21 ear pain
22
edema
23 extremity pain
24 eye trauma
25 fever
26 fatigue
27 foot ulcers
28 fracture/dislocation
29 GI bleed
palpitations
56
syncope
cardiac markers/EKG
FACTORS EFFECTING HEALTH
adverse drug reactions
83 chronic disease
smoking
108 fungal infections
hypertension
116 mood disorders
26
Venous thrombosis
Clerkship
• Internal Medicine Selective or Elective
• Academic ½ day:
– Internal medicine- ½ day CV topics (CP, CHF, ECG, HTN)
– Surgical ½ day – request to consider cardiac surgery
topic(s)- ie. post CABG or post valve replacement care
(at the level of a generalist). This topic would be better
after some clinical exposure (ie. not in M1 or M2).
Overall- Positive Aspects
• Excellent opportunity to scrutinize the course, find
gaps/redundancies, improve course in terms of
objectives, content, organization, sequencing and
teaching methods.
• Dividing into M1 and M2 is logical; M2 will be far
better understood after learning the basic sciences of
all the systems first.
• Large course, crosses over many other related
disciplines and longitudinal themes
• Current course- minimal gaps (but still some); have
identified areas to decrease redundancy
• Excellent opportunity to enhance learning with
optimal integration of the longitudinal courses
Overall- Challenges
• Very condensed timing for M2- would have been ideal to
combine with Respirology for obvious reasons
• Division of M1 & M2 and sequencing
• Number of lecturers will be more than ‘ideal’-- even just for
the core Cardiology lectures (I can’t do them all), and
adding the other related disciplines (ICU/vascular surgery,
cardiac surgery) and longitudinal themes (geriatrics, peds,
genetics, ID, pathology, radiology, etc…)
• There are a lot of GFT cardiologists (25) – trying to be fair in
distributing the teaching ‘duties’ while at the same time,
focusing on student needs to have the best teachers.
Agenda of CuRE is fewer teachers- but if only 4-6 teachers,
huge amount of hours for them (difficult to sell this model
to these 4-6 teachers when majority not participating).
Also, some want to teach, but may not get ‘picked’- may
be ‘hard feelings’.
• Clinical skills
Next Steps
• Committee to be subdivided to ‘clean up’
gaps/redundancies in their area (ie.
physiology, IHD sections), develop objectives,
then develop content.
• Teaching format to be determined- direction
from CuRE. Challenges with being such a large
course- difficult to reduce lectures to <25%;
ideal to use on-line module teaching methods,
but development will be a lot of work up
front. May need to gradually make changes.
• Consider role for purchasing material- ie. ECG
tutorials etc… for student self study.