W. Hamlar. Unity College.
Disinfection and sanitation Livestock The disease in livestock may be avoided by employing good sanitation and animal management practices e discount lyrica 150mg. Preventing the introduction of infection through movement controls cheap lyrica express, testing and quarantine order 75mg lyrica with mastercard. Detecting any infected animals in the population as early as possible through surveillance, and thoroughly investigating all suspect cases. Eliminating any confirmed infection found in livestock through the slaughter of infected and exposed animals. Cleaning and disinfection of calving areas and other places likely to become contaminated with infective material. Placing barriers around stored feed and utilising biosecurity measures to decrease interaction between wildlife and livestock in areas with a wildlife reservoir. Wildlife Control of the infection in wildlife requires management at the ecosystem scale. Eradication in wildlife is probably not feasible, but the following measures can help reduce prevalence: Preventing and controlling infection in domestic animals. Avoiding provision of artificial feeding grounds which concentrate susceptible animals (if existing, slowly phase-out). Protecting existing habitat and migration corridors (and increasing them where possible). Avoiding test-and-slaughter programmes as these have not been shown to control the disease but have been shown to exacerbate spread. Vaccination may be possible on a wildlife-appropriate scale if well thought-out and modelled beforehand. Wearing protective clothing (gloves, masks) when handling reproductive tissues (assisting delivery of newborn animals). The disease causes little morbidity or mortality, but effects at the population level are largely unknown. It can result in a negative perception of wildlife and increase exposure of wildlife to brucellosis (and additional diseases) through practices used to control movement, e. Effect on livestock Deaths are rare except in unborn animals, but the disease can be debilitating with obvious loss of productivity and welfare implications. Effect on humans Human infection frequently occurs in regions where brucellosis persists in domestic animals. It is an important human disease in many parts of the world especially in the Mediterranean countries of Europe, north and east Africa, the Middle East, south and central Asia and Central and South America and yet it is often unrecognised and unreported. Economic importance In developing countries, the disease in livestock has serious impacts on the livelihoods of farmers and may pose a barrier to trade or increase costs to farmers for testing and vaccination. The illness in humans is multisystemic and can result in economic losses due to the time lost from normal activities. Animal production & health paper - guidelines for coordinated human and animal brucellosis surveillance (2003) http://www. The bacterium is found commonly in the intestines of healthy livestock and poultry but also in most species of wild mammals and birds, other wildlife and the environment, surviving in mud slurries and polluted water for up to three months. The prevalence of infection in animals is much higher than the incidence of disease. The infection can spread rapidly between animals, particularly when they are gathered in dense concentrations. Humans usually contract the bacteria through the consumption and handling of contaminated meat and water but also through direct contact with infected animals and their faeces. Illness usually occurs in single, sporadic cases, but it can also occur in outbreaks, when a number of people become ill at one time. Species affected Many species of domestic and wild animals including cattle, sheep, goats, pigs, dogs, cats, poultry (including ducks and geese), wild birds, rodents and marine mammals. In humans, infections are particularly common in very young children in developing countries and young adults in developed countries. How is Campylobacter Direct contact with infected faeces, vaginal discharges and abortion transmitted to animals? Water courses can easily become contaminated from infected faeces of livestock and wild birds. Exactly how the infection spreads between and within herds and flocks is not fully understood due to the difficulties of detecting clinical signs in animals. Few studies exist of the transmission between wild and domestic animals, but what evidence there is suggests this is rare. How is Campylobacter Most commonly transmitted by handling and ingesting contaminated food, transmitted to humans? Also transmitted through direct contact with infected animals and their faeces and may be spread through person to person contact if hygiene is poor. There is some evidence that feral and domestic pigeons in peri-domestic settings can carry C. Humans may suffer from watery or bloody diarrhoea, abdominal pain, fever, headache, nausea and vomiting. Recommended action if Contact and seek assistance from human and animal health professionals suspected immediately if there is suspected infection in people and/or livestock. An outbreak may mean that many humans and animals are exposed to a common contaminated food item or water source. Diagnosis Isolation of the causative agent by health professionals is needed for a definitive diagnosis. Faeces or blood cultures are used for isolating the bacteria in humans, and in mammals and birds, faeces, rectal swabs and/or caecal contents are required. Samples from dead cattle, sheep and pigs are collected from the intestines by aseptically opening the gut wall. Samples should ideally be transported to the laboratory the same day but if not, within two days. Samples must be protected from light and not kept in high (>20°C) or low (<0°C) temperatures. Transmission of bacteria from animals to humans and between captive animals can be more easily prevented and controlled. Monitoring and surveillance Recording the incidence of outbreaks can identify trends in Campylobacter spp. Monitoring of outbreaks in animals and humans can also help assess the contribution of animals to human illness. Good biosecurity will help protect captive animals from bacteria and prevent cross-contamination: - Have disinfection facilities for hands, footwear, clothing, equipment and vehicles/trailers on entering or leaving areas with livestock and after contact with animals. Vector control - although not the most important mode of transmission, vector control will help prevent/reduce flies mechanically transferring Campylobacter spp.
Complications Aetiology Atrial ﬁbrillation is common discount 75mg lyrica mastercard, particularly in alcoholic r Half the cases are due to an autosomal dominant in- cardiomyopathy 75mg lyrica fast delivery, and bouts of ventricular tachycardia herited point mutation of the β myosin heavy chain purchase lyrica now, may occur. Mural thrombosis may occur in either ven- which codes for a component of the cardiac muscle tricle with the associated risk of systemic embolisation. This may raphy cannot obtain adequate views particularly in result in obstruction to the outﬂow of the left ventricle, apical hypertrophy. Clinical features Hypertrophic cardiomyopathy often presents similarly Management r β-blockade is the mainstay of treatment as this lowers to aortic stenosis with dyspnoea, angina, syncope, or sudden death. Initially the pulse is jerky with a rapid outﬂow due to hypertrophy, in the late stages ob- prevent ventricular arrhythmias and there is increas- struction results in a slow rising pulse. This may pertrophied septal wall (myotomy/myectomy) is in- be varied by dynamic maneouvres or drugs that can al- dicated with, where necessary, a mitral valve replace- ter the degree of functional obstruction. Surgical intervention is usually reserved for sound is often heard caused by ventricular ﬁlling due to severely symptomatic patients. ItisassociatedwithWolff– diuretics should only be used with care as these in- Parkinson–White Syndrome. Prognosis Macroscopy/microscopy Factors suggesting a worse prognosis include young age Hypertrophy is asymmetrically distributed. Disorganised branching of abnormal, short, thick muscle ﬁbres, in which there are large nuclei. Chapter 2: Disorders of pericardium, myocardium and endocardium 71 Aetiology Disorders of the endocardium Amyloidosis, scleroderma, sarcoidosis, iron storage dis- eases (haemochromatosis) and eosinophilic heart dis- Infective endocarditis ease (endomyocardial ﬁbrosis and Loeﬂler’s eosinophilic Deﬁnition endocarditis). Pathophysiology Inﬁltrativediseasecausingadecreaseinventricularcom- Incidence pliance (increase in stiffness) affecting the myocardium. The result is a failure of relaxation during diastole, im- pairment of ventricular ﬁlling and compromise of car- Aetiology diacoutput. Valvesmayalsobeaffectedbytheunderlying Although infective endocarditis may occur on normal disease. Patients most at risk in- clude those with rheumatic valve disease, mitral valve Clinical features prolapse, bicuspid aortic valve, coarctation, ventricular Patients present in a similar way to constrictive peri- septal defect or persistent ductus arteriosus. Enlarged liver, ascites and peripheral The clinical pattern is dependent on the infective organ- oedema may all be seen. It is an upper Thrombus formation is common, and arrhythmias and respiratory tract commensal. Differentiation from r There are many other rarer bacterial causes and fungal constrictive pericarditis using these methods can be dif- causes include Candida, Aspergillus and Histoplasma. Deﬁnitive diagnosis may require cardiac catheter- The disease is also dependent on the portal of entry, and isation and cardiac biopsy. Low-dose diuretics and vasodila- r Central lines and intravenous drug abuse (tricuspid tors may provide some relief from symptoms. Pathophysiology Prognosis The clinical picture of infective endocarditis is a balance The condition is commonly progressive. The result is either an r Splinter haemorrhages, linear dark streaks seen in the acute infection or a more insidious (subacute) course. The bacteria proliferate on the endocardium, causing r Janeway lesions are small, ﬂat, erythematous lesions the development of friable vegetations containing bac- on soles and palms, particularly the thenar and hy- teria, ﬁbrin and platelets. The disease process predisposes to the forma- mucosa of pharynx and retinal haemorrhages may tion of thrombus with the potential for emboli. Cytokine be seen (Roth’s spots are haemorrhages with a pale generation causes fever. Afever and a new or changing murmur is endocardi- r Full blood count shows an anaemia with neutrophilia. Urine cultures may be required to identify r Acute bacterial endocarditis presents with fever, new aurinary tract infection, and renal ultrasound may be or changed heart murmurs, vasculitis and infective indicated to demonstrate a renal abscess. Severe acute heart failure may occur due to r Chest X-ray may show heart failure or pulmonary in- chordal rupture or acute valve destruction. General signs: r Malaise, pyrexia, anaemia and splenomegaly, which Complications may be tender. Cerebral emboli may cause infarction or my- disturbance due to the valve lesion(s), e. Chapter 2: Hypertension and vascular diseases 73 Management carditis; this is due to changing patterns of the disease It is important to identify the organism responsible (elderly, drug addicts, prosthetic valves, antibiotic resis- for the endocarditis; however, this should be balanced tance). Once cultures are sent, intravenous antibiotics should be commenced based on the most likely pathogens if there is a high suspicion of Hypertension and vascular bacterial endocarditis. The r When the culture results are known endocarditis World Health Organisation latest guidelines deﬁne hy- should be treated with the most appropriate antibi- pertension with three grades of severity that reﬂect the otics. It is best to have a multidisciplinary approach fact that systolic and diastolic hypertension are indepen- with early microbiological and surgical advice. M > F The timing of surgery is a balance between the desire to eradicatebacteriapriortotheprocedureandtheneedfor early surgery due to the compromised haemodynamic Geography state. Aftersurgeryafullcourseofdrugtreatmentshould Rising prevalence of hypertension in the developing be given to eradicate the organisms. For example, amoxycillin for dental procedures, tension: and amoxycillin and gentamicin for oropharyngeal, gas- Essential hypertension (>90%) r Non-modiﬁable: Genetic (racial and familial), gender trointestinal or genitourinary procedures. Prognosis r Modiﬁable: Obesity, alcohol intake, diet (especially Despite advances in treatment, overall mortality is still high salt intake). Complications Hypertension is a major risk factor for cerebrovascular Pathophysiology disease (strokes), heart disease (coronary artery disease, r Hypertension accelerates the age-related process of left ventricular hypertrophy and heart failure) (see Table arteriosclerosis ‘hardening of the arteries’ and predis- 2. Arterioscler- include peripheral vascular disease and dissecting aortic osis, through smooth muscle hypertrophy and intimal aneurysms. In r The chronic increased pressure load on the heart re- severehypertension,retinalhaemorrhages,exudatesand sults in left ventricular hypertrophy and over time this papilloedema are features of malignant hypertension. Saltand r Benign hypertension and small arteries: There is hy- water retention occurs, which can itself worsen hyper- pertrophy of the muscular media, thickening of the tension. In cases of doubt, r Routine investigations must include fasting plasma 24-hour blood pressure recordings may be helpful such glucose, serum total cholesterol and lipid proﬁle, as when ‘white coat’ hypertension is suspected. Management Peripheral arterial disease Treatment is based on the total level of cardiovascular Deﬁnition risk and the level of systolic and diastolic blood pressure Peripheralarterialdiseasedescribesaspectrumofpatho- (see Tables 2. Stopping smoking as well as the ac- tions mentioned above will also reduce overall cardio- Age vascular risk. If after 3 months their M > F systolic blood pressure is above 139 or the diastolic above 89, treatment should be started. The remainder Geography of patients and those with low or average risk should More common in the Western world. Atheromatous plaques form especially in larger vessels at areas of haemodynamic stress such as at the bifurcation Prognosis of vessels and origins of branches. It may affect younger Patients with untreated malignant hypertension have a patients, particularly diabetics and smokers. In general the risks from Arteriosclerosis, ‘hardening of the arteries’, is an age- hypertension are dependent on: related condition accelerated by hypertension.
The limbic system is activated by healthy generic 150 mg lyrica visa, life-sustaining activities such as eating and socializing— but it is also activated by drugs of abuse cheap generic lyrica uk. In addition order lyrica 75mg online, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the mood-altering properties of many drugs. Networks of neurons pass messages back z Receptors—The Brain’s Chemical Receivers and forth among different structures within the brain, the spinal cord, The neurotransmitter attaches to a specialized site on the receiving and nerves in the rest of the body (the peripheral nervous system). A neurotransmitter and its receptor oper- These nerve networks coordinate and regulate everything we feel, ate like a “key and lock,” an exquisitely specific mechanism that think, and do. Once a cell receives and porters recycle these neurotransmitters (that is, bring them back processes a message, it sends it on to other neurons. The neurotransmitter crosses the synapse and attaches to proteins (recep- tors) on the receiving brain cell. This causes changes in the receiving cell—the Transmitter Receptor Neurotransmitter Receptor message is delivered. Madras Most drugs of abuse target the brain’s reward system by flooding it with dopamine. Drugs are chemicals that affect the brain by tapping into its communication system and interfering with the way neurons normally send, receive, and process information. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure “fools” receptors and allows the drugs to attach onto and activate the neurons. Although these drugs mimic the brain’s own chemicals, they don’t activate neurons in the same way as a natural neurotransmitter, and they lead to abnormal messages being transmitted through the network. Other drugs, such as amphetamine or cocaine, can cause the neurons to release abnormally large amounts of natural neuro- transmitters or prevent the normal recycling of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. Most drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, motivation, and feelings of pleasure. Overstimulating the system with drugs, however, produces euphoric effects, which strongly reinforce the behavior of drug use—teaching the user to repeat it. When some drugs of abuse are taken, they can release 2 to 10 times Our brains are wired to ensure that we will repeat life-sustaining activ- the amount of dopamine that natural rewards such as eating and sex 15 ities by associating those activities with pleasure or reward. In some cases, this occurs almost immediately (as when drugs this reward circuit is activated, the brain notes that something impor- are smoked or injected), and the effects can last much longer than tant is happening that needs to be remembered, and teaches us to do it those produced by natural rewards. Because drugs of abuse pleasure circuit dwarf those produced by naturally rewarding behav- 16,17 stimulate the same circuit, we learn to abuse drugs in the same way. The effect of such a powerful reward strongly motivates peo- ple to take drugs again and again. When cocaine is taken, dopamine increases are exaggerated, and communication is altered. As a result, dopamine’s For the brain, the difference between normal rewards and impact on the reward circuit of the brain of someone who drug rewards can be described as the difference between abuses drugs can become abnormally low, and that per- someone whispering into your ear and someone shouting son’s ability to experience any pleasure is reduced. Just as we turn down the volume on a This is why a person who abuses drugs eventually feels flat, radio that is too loud, the brain adjusts to the overwhelm- lifeless, and depressed, and is unable to enjoy things that were previously pleasurable. Also, the person will often need to take larger amounts of the drug to produce the familiar dopamine high—an effect known as tolerance. We know that the same sort of mechanisms involved in the development of tolerance can eventually lead to profound Healthy Control Drug Abuser changes in neurons and brain circuits, with the potential to severely compromise the long-term health of the brain. For 20 example, glutamate is another neurotransmitter that influences the W hat other brain changes reward circuit and the ability to learn. Chronic exposure to drugs of abuse disrupts the way critical brain Similarly, long-term drug abuse can trigger adaptations in habit or structures interact to control and inhibit behaviors related to drug use. Conditioning is one example of this Just as continued abuse may lead to tolerance or the need for higher type of learning, in which cues in a person’s daily routine or environ- drug dosages to produce an effect, it may also lead to addiction, which ment become associated with the drug experience and can trigger can drive a user to seek out and take drugs compulsively. Drug addic- uncontrollable cravings whenever the person is exposed to these cues, tion erodes a person’s self-control and ability to make sound deci- even if the drug itself is not available. This learned “reflex” is extreme- sions, while producing intense impulses to take drugs. Imaging scans, chest X-rays, and blood tests show the damaging effects of long-term drug Pabuse throughout the body. For example, research has shown that tobacco smoke causes cancer of the mouth, throat, larynx, blood, 19 lungs, stomach, pancreas, kidney, bladder, and cervix. In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system. Three of the Injection drug use is also a major factor in the spread of hepatitis more devastating and troubling consequences of addiction are: C, a serious, potentially fatal liver disease. Injection drug use is not z Negative effects of prenatal drug exposure on infants the only way that drug abuse contributes to the spread of infectious and children diseases. It is also likely that some drug- hepatitis B and C, and other sexually transmitted diseases. According to the Surgeon General’s 2006 Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, involuntary exposure to secondhand smoke increases the risks of heart disease and lung cancer in people who have never 20 smoked by 25–30 percent and 20–30 percent, respectively. Tobacco use is responsible for an estimated 23 5 million deaths worldwide each year. Tobacco smoke increases a user’s risk Throat of cancer, emphysema, bronchial disorders, and cardiovascu- Larynx (voice box) Mouth Esophagus lar disease. Tobacco use killed approximately 100 mil- Lung Blood (leukemia) lion people during the 20th century, and, if current smoking Stomach Kidney Pancreas trends continue, the cumulative death toll for this century has Bladder Cervix 24 been projected to reach 1 billion. However, misuse or abuse of these drugs (that is, taking impairs short-term memory and learning, the ability to focus attention, them other than exactly as instructed by a doctor and for the purposes and coordination. It also increases heart rate, can harm the lungs, prescribed) can lead to addiction and even, in some cases, death. Unfortunately, there is a common misperception that because medications are prescribed by physicians, they are safe even when used illegally or by another person than they were prescribed for. Users also may have traumatic experiences and ucts, such as oven cleaners, gasoline, spray paints, and other emotions that can last for many hours. It slows respiration, and its use is linked to an toxic and can damage the heart, kidneys, lungs, and brain. Even a increased risk of serious infectious diseases, especially when taken healthy person can suffer heart failure and death within minutes of intravenously. People who become addicted to opioid pain relievers a single session of prolonged sniffing of an inhalant. Serious consequences of abuse can z Amphetamines, including methamphetamine, are powerful stim- include severe acne, heart disease, liver problems, ulants that can produce feelings of euphoria and alertness. Methamphetamine’s effects are particularly long-lasting and harmful z Drug combinations. Amphetamines can cause high body temperature and and common practice is the combining of two or more drugs. It can increase body temperature, heart rate, blood drugs, to the deadly combination of heroin or cocaine with fentanyl pressure, and heart-wall stress.
If you fed that you have a problem with chronic buy cheap lyrica online, ongoing overacidity (see section on Monitoring Arid/Alkaline Levels in this chapter) order lyrica toronto, make certain that you decrease or eliminate meat while using urine therapy buy genuine lyrica on line. Also, improve your diet by eating more alkaline foods, and decreasing arid foods before and after you start on urine therapy. Monitor your add/alkaline level with pH strips to determine when your pH has returned to a normal or more balanced condition. In cases of chronic addosis (over-acidity), do not do extended urine fasts or ingest large quantities over long periods of time. Use oral drops to begin; start with 1-2 drops once a day, and gradually increase to 5-10 drops two to four times a day, for one to three weeks, depending on your need. Monitor your pH levels and your symptoms (see symptoms of addosis in this chapter). You can also dilute the urine in water, or use a homeopathic preparation of your urine. The amount of time needed to achieve results with urine therapy is different for every person and each condition. Many people have found that chronic, long-standing complaints require a longer period of time to heal, while others experience rapid resuite. In general, do not use large amounts of urine infernally for more 207 than two to three weeks at a time. A maintenance dose for many people is one to two ounces of morning urine per day, although even 2-5 drops of morning urine per day or every oiher day could be considered a good maintenance dose, especially for those with acidosis or weak kidneys. There are several excellent urine testing kits that have been developed in the last few years that can be used at home and can save you an amazing amount of time and money. Now you can perform many of the same urine tests at home that your doctor performs in hia office. Also, these tests are particularly helpful when using urine therapy because you can monitor your own health progress easily and inexpensively. The booklet also explains how to interpret your urine color and appearance which are important additional indicators of health conditions. Many of the research tests on urine recycling have been undertaken with animals, and vetermarians have used urine therapy for treatment by catherizing the arumal and administering oral urine drops with reportedly good results. Urine home test strips are available to test for these conditions and many others: o Kidney and Urinary Tract Infections o Diabetes o Blood in the urine o Pregnancy o Ovulation 208 o Liver Function You can purchase these strips in drug- stores or they are available by catalog Summary Remember to begin your treatment slowly with a few oral drops and increase the amount to a well-tolerated dosage. Do not use the therapy while ingesting heavy amounts of nicotine, caffeine or while using recreational drugs or therapeutic drugs than small amounts. If you do decide to use it, however, use only very small amounts (3-5 drops 1x day. Drink as much water as you feel thirsty for, and keep weli-hydrated, but do not force-drink large amounts oi fluid during the therapy. Daily maintenance doses vary from a few drops to one to two ounces of morning urine, depending on your sensitivity and preference. Start with small amounts and work up to larger amounts gradually for internal use. Do Not combine urine therapy with a starvation diet (or fasting) unless you have been using the therapy for at least two months. Beginning in 1983, the school moved in-stages to the new branch campus in Kubang Kerian, Kelantan. The Health Campus is fully equipped with up-to-date teaching, research and patient care facilities. One of the unique features of the School of Medical Sciences is its integrated organ-system and problem-based curriculum. The course aims to produce dedicated medical practitioners who will be able to provide leadership in the health care team at all levels as well as excel in continuing medical education. More specifically, the student upon graduation, should be able to:- (a) Understand the scientific basis of medicine and its application to patient care. This ‘spiral’ concept enables the school to implement the philosophy of both horizontal and vertical integration of subjects/disciplines. The Medical School in formulating the new curriculum, studied the various problems in established medical faculties parri passu with new developments in medical education. The study of behavioural sciences and exposure to the clinical environment are also incorporated. Clinical work and hospital attachments account for a high percentage of the student’s time in these two years. Emphasis is given to problem - solving, and clinical reasoning rather than didactic teaching. Apart from this clinical exposure, the student is also orientated to health care delivery services within the teaching hospital and the network of supporting hospitals and health centres in the region. The aim is to inculcate a sense of professional responsibility and adaptability so that the student will function effectively when posted later to the various health care centres in the country. The teaching strategy implemented in this phase reflects these approaches:- 28 (i) Discipline - based (ii) Multi-diciplinary integration (iii) Problem - based and problem-solving (iv) Community-orientated (v) Clinical apprenticeship A. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of cell, tissue and embryology will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 2. Snell, Clinical Anatomy, 7th Ed, (2003), Lippincott Williams and Wilkins Physiology 1. Kumar et al, Robbin and Cotran: Pathology Basis of Disease, 8th ed (2010), SaundersElsevier. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of molecular biology and pharmacology will be evaluated through continuous assessment using formative and summative approaches. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill,. Lectures and learning activities outside the lecture hall such as hospital placement with other health care workers and community projects will be used to help students understand and appreciate the importance, and practice basic medical ethics and communication. Lectures and practical basic first aid will be given to provide early exposure to students on patient care. Basic knowledge and understanding of the key principles of first aid and medical ethics will be evaluated through continuous assessment using formative and summative approaches. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of immunology, microbiology and pathology will be evaluated through continuous assessment using formative and summative approaches.