Level: 6
Credits: 15
Module leader: Danielle Fullwood
Tel: 020 7848 3687
Email: danielle.r.fullwood@kcl.ac.uk
Academic support: Tutorial times have been incorporated into the course timetable
This handbook must be read in conjunction with module information provided on KEATS , the King’s E-
Learning And Teaching Service. You will be given access to KEATS on enrolment. Important information relating to assessment and related regulations can be found in the Postgraduate/Undergraduate ( please delete as appropriate) Programme Handbook, available on KEATS and via the Student Services Centre .
This handbook can also be provided in alternative formats (such as large print) upon request to asc@kcl.ac.uk
.
1

Module overview ................................................................................................................ 3
Module aims ................................................................................................................... 3
Learning outcomes ......................................................................................................... 3
Teaching arrangements .................................................................................................. 3
Timetable ....................................................................................................................... 4
Submitting coursework/exam information ......................................................................... 7
Assessment criteria ........................................................................................................ 7
Formative assessment .................................................................................................... 7
Summative assessment .................................................................................................. 7
Submission date for course work: ................................................................................... 7
Results and re-submissions for course work ................................................................... 8
Re- submission date: ...................................................................................................... 8
Learning resources ............................................................................................................. 9
Session Two: Alpha 1 Antitrypsin Deficiency ...................................................................... 14
Indicative reading ............................................................................................................... 16
Journals .............................................................................................................................. 16
Web sites ............................................................................................................................ 16
Module evaluation .............................................................................................................. 16
Action from previous evaluations ....................................................................................... 16
2

Module aims
This module will enable practitioners to develop their knowledge base in caring for patients with liver diseases. The focus will predominately be on chronic liver disease, although the course will provide an overview of acute liver failure and transplantation.
Learning outcomes
The learning outcomes of this course meet some of the nine liver care competencies as set out by the Royal
College of Nursing, NHS Liver Care and the Department of Health in the 'Caring for people with liver disease: a competence framework for nursing' (2013).
1.
Analyse and apply the evidence base that underpins the medical and nursing management of patients with liver disorders, both in a Hepatology or general setting.
2.
Appraise the knowledge and skills needed for assessment planning, delivery and evaluation of care for patients with liver disease
3.
Appraise and evaluate the contribution of nursing and other professional groups in the management and delivery of effective care to patients with liver disease
4.
Analyse the factors influencing health care promotion for patients with liver disease
5.
Examine the factors which determine the provision of health care resources taking into account the importance of cost, efficiency, quality and resources available
Teaching arrangements
The educational approach is adult student centred, which builds on your experience as a qualified practitioner. You will experience a wide variety of teaching and learning strategies:

Lecture and discussion

Group work

Tutorials

Guided study

Quiz

Independent study

Case study exploration

E-learning
3

Timetable
Please note the timetable is subject to change
Day and Date
Day One (All)
25/9/2015
Venue Time
FWB 5.132 11.00-11.30
FWB 5.132 11.30-12.15
Topic
Welcome and introduction to the liver course
Speaker
FWB 5.132 12.15-13.00
JCMB B17 14.00-15.00
Quiz and introduction to the anatomy and physiology of the Liver
Chronic liver disease: setting the scene
The effect of chronic liver disease on other body systems (Respiratory and cardiovascular)
JCMB B17 15.00-16.00 Understanding and assessing a patient’s Liver
Function and dispelling the myths about Hemostasis
Day Two (All)
2/10/15
Self study 10.00-11.00 E-learning Self study
Day Three
FWB 5.132 11.00-12.00 Causes of jaundice and care of the jaundiced patient
FWB 5.132 12.00-13.00
JCMB B17
JCMB B17
Self study
14.00-15.00
15.00-16.00
10.00-11.00
Ascites and management in patients with Chronic Liver disease
Hepatorenal syndrome and renal complications
Portal Hypertension and managing a patient with a variceal bleed
E-learning Self study
4

(All)
9/10/15
FWB 1.70
FWB 1.70
FWB 4.63
11.00-12.00
12.00-13.00
14.00-15.00
Day Four (Adult nurses only) 16/10/15
FWB 4.63
FWB 4.63
Self study
15.00-16.00
16.00-17.00
10.00-11.00
JCMB G14 11.00-12.00
JCMB G14 12.00-13.00
FWB 1.17 14.00-15.00
FWB 1.17 15.00-15.30
Day 4Four (Paediatric nurses only)
23/10/15
FWB 1.17
Self study
15.30-16.00
10.00-11.00
WEC
Classroom 3
11.00.11.30
WEC
Classroom 3
11.30-12.15
WEC
Classroom 3
12.15-13.15
WEC
Classroom 3
14.00-15.00
Hepatitis B virus
Hepatitis C virus
Managing patients with
Hepatic Encephalopathy in
Chronic Liver disease
Acute Pancreatitis
Optional essay workshop
E-learning and tutorials Self study
Hepatocellular Carcinoma
Pancreatic, hepatobiliary and neuro-endocrine cancers
Alcohol related liver disease
Caring for a patient with
Non Alcoholic Fatty Liver disease
PBC/PSC
E-learning and tutorials Self study
Small Bowel
Transplantation
Alpha 1 Antitrypsin
Deficiency
Childhood liver cancers
Nutrition in children with chronic liver disease
5

Day Five
(All) 30/10/15
WEC
Classroom 3
15.00-16.30
Self study 10.00-11.00
Biliary Atresia and autoimmune diseases
E-Learning and tutorials Self study
FWB 5.132
FWB 5.132
11.00-12.30
12.30-13.00
WBW G552 14.00-16.00
Acute Liver Failure and transplantation
Immunosuppression for the post transplant patient
Issues in Transplantation for patients with chronic liver disease
6

Assessment criteria
Essay 2000 words. This contributes to 100% of the overall grade
You will demonstrate an achievement of the course learning outcomes by writing an assignment addressing either a liver disease or a complication of liver disease as identified in a patient-based case study.
Formative assessment
 Students are advised to seek tutorial support from the course lecturer. This should be a student led discussion focusing on the students’ essay. The student should provide a plan in which the key themes are identified along with relevant literature using the bullet points below. o Which patient case study have you chosen? o What disease/complication aspect will you focus on? o Identify the key references which you will use to support the pathophysiology/management of the chosen aspects o Is the evidence clear? Are there any opposing views? How does it relate to your practice?
Summative assessment

Your assignment must be in a structured essay format, but sub heading may be used. It should include an introduction, main body and conclusion

Critically appraise the management of either the chosen liver disease or complication of liver disease which may be carried out to address the patients’ health care needs, this must include a critical appraisal of the nurses’ role and nursing practice in relation to the identified management

Critically analyse the evidence-based literature in relation to both the patients problem, interventions and nursing management

Make recommendations for future nursing practice in relation to your analysis of the interventions and nursing management of your identified complication

Your assignment needs to be appropriately referenced using the Harvard referencing system (please see post registration handbook for guidance)
Course work submission/exam instructions are provided on the KEATS module page.
It is essential that you use your candidate number on all assignments/examinations. Your candidate number, will be available via Student Records on the King’s Intranet approximately one month after you enrol.
Submission date for course work:
5 th January 2016
Late Submissions
Late submissions will be accepted for 24 hours following the submission date. All work submitted late will be marked as normal but will be capped at the pass mark for the module. If your assignment is submitted electronically through TurnItIn, information about how to submit late will be provided on KEATS module sites under assessment information.
7

Results and re-submissions for course work
Students will receive a provisional (unratified) mark for their coursework 4 weeks following submission.
According to the method of submission as detailed on your KEATS site, if your work was submitted online you will be able to download marked coursework from KEATS ; alternatively, if you completed a hard-copy submission you can collect your coursework and feedback from the Student Services Centre .
To collect a hard copy assignment, you must provide your candidate number. Alternatively, you may send a stamped addressed envelope to the Student Services Centre ensuring that this is large enough to accommodate your assignments and that you have applied sufficient postage. Hard copy assignments will be retained for four weeks; if you have not collected your assignment by then, it will be destroyed.
Feedback will include the award of a numerical grade which remains provisional until ratified by the examination boards. The dates for the examination boards are available on KEATS . Ratified marks can be viewed via Student Records on the King’s Intranet , the Monday following the relevant examination board.
If you are unsuccessful, it is recommended that you contact the module leader before submitting your second attempt. This will enable the module lead to provide you with an appropriate level of support as you prepare to re-submit your work.
Re- submission date:
12 th April 2016
8

Day 1: 25 th September 2015
Session One: Course introduction, ice breaker and Quiz
By the end of this session the students will be able to:

Demonstrate familiarity with the course structure and content

Demonstrate familiarity with other course students

Understand the principles of e-learning and self directed learning

To understand how to access KEATS liver disease module 6KNIN 337

Differentiate between acute and chronic liver disease

Acknowledge the common aetiologies of liver failure

Understand the anatomy of the Liver and the main functions
Indicative reading

Module Handbook

Post Qualification Handbook

Hill C (2009) Anatomy and Physiology. Chapter 1. In Sargent S (2009) Liver Diseases; an essential guide for nurses and health care professionals. Wiley-Blackwell.
Session Two: Chronic liver disease; setting the scene
By the end of the session students will

Understand the UK prevalence of chronic liver disease

Understand the most common aetiologies

Recognise stigmata of chronic liver disease and reasons for these
Indicative reading

NHS Liver care website http://www.liver.nhs.uk/

Liver matters on-line newsletter accessed through http://www.livermatters.nhs.uk/
Session Three: The effect of chronic liver disease on other body systems (Respiratory and cardiovascular)
By the end of the session the student will be able to

To analyse the respiratory and cardiovascular complications of chronic and acute liver failure

To revise the relevant pathophysiology of occurrence

To examine current treatments and evaluate effectiveness

Explore the current nursing management of respiratory and cardiovascular complications in patients with liver diseases
Indicative reading
 Møller S & Bernardi M (2013) Interactions of the heart and the liver. European Heart Journal 34; 2804-

2811
Yang YY & Lin HC (2012) The heart: Pathophysiology and clinical implications of cirrhotic cardiomyopathy. Journal of the Chinese Medical Association 75; 619-623
9

Session Four: Understanding and assessing a patient’s Liver Function and dispelling the myths about
Hemostasis
By the end of the session the students will be able to:

Differentiate between liver enzymes and liver function tests

To analyse normal and abnormal values and the relation to liver disease

To understand how Hemostasis changes in Liver disease

To debate appropriate interventions and precautions in managing coagulopathy in liver disease
Indicative reading

Greenslade L (2009) Assessment of liver function and diagnostic studies in Sargent S (ed) (2009) Liver
Diseases; An Essential Guide for Nurses and Health Care Professional Oxford; Wiley-Blackwell

Patch D & Dhillon AP (2011) Chapter 3 Biopsy of the Liver in Dooley JS, Lok ASF, Burroughs AK &
Heathcote EJ (2011) Sherlock’s Diseases of the Liver and Biliary System. 12 th Edition. Wiley-Blackwell

Northu PG & Caldwell SH (2013) Coagulation in Liver Disease; a guide for the clinician. Clinical
Gastroenterology and Hepatology 11; 1064-1074

Tripodi A & Mannuccio Mannucci P(2010) Abnormalities of haemostasis in chronic liver disease:
Reappraisal of their clinical significance and need for clinical and laboratory research. Journal of
Hepatology 46; 727-733
Day 2: 2 nd October 2015
Session One: The Jaundiced patient
By the end of the session the student will be able to

To revise the anatomy and physiology of liver cells and biliary system to understand the flow of bile

To examine the differences between conjugated and unconjugated bilirubin

To examine the pre hepatic, hepatic and post hepatic causes of jaundice

To analyse current treatments and nursing management

To analyse and evaluate the psychological impact of altered body image
Indicative reading

Clayton M (2009) Jaundice in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nurses and
Health Care Professionals Oxford; Wiley-Blackwell

Elias E (2011) Chapter 11 Jaundice and Cholestasis in Dooley JS, Lok ASF, Burroughs AK & Heathcote EJ
(2011) Sherlock’s Diseases of the Liver and Biliary System. 12 th Edition. Wiley-Blackwell
Session Two: Ascites and management
By the end of the session the student will be able to

To examine the pathophysiology of ascites and diagnostic criteria

To analyse the dietary, medical and surgical approaches to the management of patients with ascites

To analyse and evaluate the nursing management of patients with ascites
10

Indicative reading

EASL (2010) Clinical Practice Guidelines on the management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis. Journal of Hepatology 53; 397-417

Fullwood D & Purushothaman (2014) Managing ascites in patients with chronic liver disease. Nursing
Standard 28(23)51-58
Session Three: Acute Kidney Injury and Hepatorenal Syndrome in chronic liver disease
By the end of the session the student will be able to

To identify causes of acute kidney injury in patients with chronic liver disease and some of the management strategies

To demonstrate increased understanding of the pathophysiological factors underpinning hepatorenal syndrome and the international ascites club diagnostic criteria

To examine the current medical and nursing strategies for patients with hepatorenal syndromes
Indicative reading

Tsien CD, Rabie R & Wong F (2013) Acute kidney injury in decompensated cirrhosis. GUT 62; 131-137

Wadai HM (2012) Hepatorenal syndrome; a critical update. Seminars in Respiratory and Critical Care
Medicine 33(1) 55-69
Session Four: Portal Hypertension and the Management of a patient with a variceal haemorrhage
By the end of the session the student will be able to

To revise the pathophysiology of portal hypertension and formation of varices

To demonstrate knowledge of the SIGN guidelines for management of variceal bleeding

To examine the emergency and long-term treatment strategies for portal hypertension
Indicative reading

Fullwood D (2012) Portal hypertension and varices in patients with liver cirrhosis. Nursing Standard 26
(48) 52-57

National Institute for Clinical Excellence (2012) Acute upper gastrointestinal bleeding management.
Guideline 141 http://www.nice.org.uk/nicemedia/live/13762/59549/59549.pdf
accessed 13/6/14
Day 3: 9th October 2015
S ession One: Overview of Viral hepatitis B
By the end of the session the student will be able to

Understand the current modes of viral transmission of hepatitis B

Explore current epidemiology both world wide and UK

Analyse serological tests for the diagnosis and treatment of Hepatitis B

Understand current treatment options for patients with Hepatitis B
Indicative reading

Oakes K (2014) Management of chronic hepatitis B virus. Nursing Times . 110(8) 20-24

EASL (2012) Revised Clinical Practice Guidelines on the Management of Chronic Hepatitis B http://www.easl.eu/assets/application/files/ef520780b91cf4f_file.pdf accessed 13/6/14
11


Sarri G, Westby M, Bermingham S, Hill-Cawthorne G, Thomas H (2013) Diagnosis and management of chronic hepatitis B virus in children, young people and adults: summary of NICE guidance. British
Medical Journal 346(7915) f3893
Session Two: Overview of Viral hepatitis C
By the end of the session the student will be able to

Understand the current modes of viral transmission of hepatitis C

Explore current epidemiology both worldwide and UK

Analyse serological tests for the diagnosis and treatment of Hepatitis C

Understand current treatment options for patients with Hepatitis C
Indicative reading

EASL (2014) Recommendation on treatment of hepatitis C infection. http://files.easl.eu/easlrecommendations-on-treatment-of-hepatitis-C/index.html accessed 13/6/14
Session Three: Hepatic Encephalopathy and management in chronic liver disease
By the end of the session the student will be able to

To revise the pathophysiology and underlying theories of hepatic encephalopathy

To review current treatment therapies and effects

Have an understanding of future therapies

To analyse and review current nursing management
Indicative reading

Houlston C, O’Neil H (2009) Hepatic Encephalopathy in Sargent S (Ed.) (2009) Liver Disease; An
Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell

Prakesh R & Mullen KD (2010) Mechanisms, diagnosis and management of hepatic encephalopathy.
Nature Reviews Gastroenterology and Hepatology 7; 515-525
Session Four; Acute Pancreatitis
By the end of the session the student will be able to

To understand the difference between acute and chronic pancreatitis

Interpret clinical and biochemical findings and link them with the pathogenesis of the disease

To analyse the current management strategies for severe acute and chronic pancreatitis
Indicative reading

Andris A (2010) Pancreatitis; understanding the disease and implications for care. AACN Advanced
Critical Care 21 (2) 195-204

Brenner Z & Krenzer M (2010) Understanding acute pancreatitis. Nursing 40 (1) 32-37
Day 4: 16 th October 2015 (Adult nurses only)
Session One and Two: Hepatocellular, hepatobiliary and pancreatic carcinomas
By the end of the sessions the student will be able to

To examine the incidence of Liver related cancers in the United Kingdom

To review both medical and surgical treatment strategies
12


Demonstrate increased understanding of the postoperative complication of hepatobiliary surgery and procedures

To examine current nursing management strategies for patients with liver related cancers
Indicative reading

EASL (2012) Management of hepatocellular carcinoma http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf
accessed 13/6/14

Jervis N (2009) in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care
Professionals Oxford; Wiley-Blackwell
Session Three: Overview and Management of Alcoholic Related Liver Disease
By the end of the session the student will be able to

To analyse current incidence and impact on the health service

To examine the pathophysiology of alcoholic liver disease, including fatty liver, alcoholic hepatitis and cirrhosis

To appraise current management for both ALD and alcoholic hepatitis
Indicative reading

Webb K (2009) Alcohol Related Liver Disease in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell

Government alcohol strategy March 2012 http://www.homeoffice.gov.uk/publications/alcoholdrugs/alcohol/alcohol-strategy?view=Binary
Session Four: Non Alcoholic Fatty Liver Disease
By the end of the session the student will be able to

To understand the increasing incidence of NAFLD

To examine the underlying pathophysiology, disease presentation and associated complications

To review the current evidence base management strategies
Indicative reading

Nikolopoulos A and Oben JA Non Alcoholic Fatty Liver Disease in Sargent S (Ed.) (2009) Liver Disease;
An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell

Sullivan S (2010) Implications of diet on non alcoholic fatty liver disease. Current opinions in
Gastroenterology 26 92) 160-164
Session Five: Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis
By the end of the session the student will be able to

To review the basic pathophysiology of cholestatic liver diseases

To examine diagnostic testing and signs and symptoms

To examine disease related complications

Appraise the effectiveness of current medical, surgical and nursing management.
Indicative reading

Fullwood D (2009) Primary Biliary Cirrhosis and Primary Biliary Cholangitis in Sargent S (Ed.) (2009)
Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell
13


Fullwood D (2009) The Diagnosis and Treatment of patient with Primary Sclerosing Cholangitis;
Gastrointestinal Nursing 7(5) 38-42

Sargent S, Fullwood D (2008) Diagnosing and treating a patient with primary biliary cirrhosis. British
Journal of Nursing, 17 (9) 566 – 570.
Day 5: 23 rd October 2015 (Paediatric nurses only)
Session One: Small Bowel Transplantation
By the end of the session the student will be able to

Understand the need for small bowel transplantation

Explore the nursing care for a patient pre and post small bowel transplant
Indicative reading

Bodeur C, Aucion J, Johnson R et al (2014) Clinical practice guidelines-Nursing management for paediatric patients with small bowel or multivisceral transplant. Journal for Specialists in Paediatric
Nursing 19(1) 90-100
Session Two: Alpha 1 Antitrypsin Deficiency
By the end of the session the student will be able to

To review the basic pathophysiology of alpha 1 antitrypsin deficiency

To examine diagnostic testing and signs and symptoms

To examine disease related complications

Appraise the effectiveness of current medical, surgical and nursing management.
Indicative reading

Konvalinka P (2010) Alpha-1 antitrypsin deficiency panniculitis. Dermatology Nursing 22(6) 23-25

Young V (2010) Living with alha-1 antitrypsin deficiency panniculitis. Dermatology Nursing 22(6) 26
Session Three: Childhood Liver Cancers
By the end of the session the student will be able to

Demonstrate and understanding of both benign and malignant liver tumours

Critically review the surgical management of liver tumours including transplantation

Critically analyse the medical management of liver tumours
Session Four: Nutrition in chronic and metabolic liver disease
By the end of the session the student will be able to

Review the pathophysiology of malnutrition in children with chronic liver disease

To evaluate the methods of assessing nutritional status

To examine formulations used in chronic, acute and metabolic liver disease
Indicative reading

Sadlier C (2008) Intestinal failure and long term parenteral nutrition in children. Paediatric Nursing 20(10)
37043
Session Five: Biliary Atresia and Autoimmune diseases
By the end of the session the student will be able to

Revise the different causes of jaundice in infants
14


Understand the use of the ‘Yellow Alert’ early identification algorithm for infant jaundice

Demonstrate an increased understanding of the epidemiology and pathophysiology of biliary atresia

Currently review medical and, surgical and nursing treatments for biliary atresia
Indicative reading

Manns MP, Czaja AJ, Gorham JD, Krwitt EL, Mieli-Vergani G, Vergani D, Vierling JM (2010) Diagnosis and management of Autoimmune Hepatitis; AASLD practice guidelines. Hepatology 51(6) 2193-2213
Day 6: 30 th October 2015
Session One: Acute Liver Failure
By the end of the session the student will be able to

To examine the clinical presentations of hyperacute, acute and sub acute liver failure.

To recognise the main aetiologies of acute liver failure

To examine clinical presentation and nursing management of encephalopathy and cerebral oedema, renal failure, coagulopathy, metabolic, cardiovascular and respiratory complications in acute liver failure

Consider the indications for referral and transplantation criteria

Evaluate the current and future research of acute liver failure management
Indicative reading

Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJW et al (2013) Lessons from look-back in acute liver failure ? A single centre experience of 3300 patients. Journal of Hepatology 59; 74-80

Lee WM, Larson AM and Stravitz T (2011) AASLD position paper: Management of Acute Liver Failure:
Update 2011. http://www.aasld.org/practiceguidelines/Documents/AcuteLiverFailureUpdate2011.pdf
accessed 11 July 2014
Session Two: Introduction to Immunosuppression for the post transplant patient
By the end of the session the student will be able to

To examine current Immunosuppression therapies in Transplantation

To look at Immunosuppression for the treatment of specific diseases of the Liver
Indicative reading

Geissler EK & Schlitt HJ (2008) Immunosuppression for Liver transplantation. Gut 58;452-463
Session Three: Liver Transplant assessment for patients with chronic liver disease
By the end of the session the student will be able to

Appraise the current transplant assessment and listing criteria for chronic transplant recipients
Indicative reading

Fullwood D, Jones F, Lau-Walker M (2011) Care of patients following liver transplantation. Nursing
Standard 25(49) 50-56

Littlejohn W, Routledge J ( 2009) in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell
15

 Dooley JS, Lok ASF, Burroughs AK & Heathcote EJ (2011) Sherlock’s Diseases of the Liver and Biliary
System. 12 th Edition. Wiley-Blackwell
 Sargent S (2009) Liver Diseases, An Essential Guide for Nurses and Health Care Professionals Oxford,
Wiley-Blackwell
British Journal of Nursing
British Medical Journal
Critical Care Medicine
Gut
Gastrointestinal Nursing
Liver Transplant Proceedings
New England Journal of Medicine
Hepatology
Journal of Advanced Nursing
Journal of Gastroenterology
Journal of Hepatology
Lancet
Nursing Standard
Transplantation
 American Association for the study of liver disease (AASLD) http://www.aasld.org
.
 British Liver Trust http://britishlivertrust.org.uk
 British Society of Gastroenterology http://www.bsg.org.uk
 Department of Health http://www.doh.gov.uk
 European Association for the Study of the Liver (EASL) http://www.easl.eu
 National Institute For Clinical Excellence (NICE) http://www.nice.org.uk
 United Kingdom Transplant services http://www.uktransplant.org.uk/ukt/default.jsp
At the end of the module you are requested to complete the short online evaluation which will be available on your module KEATS site. Student evaluations are very important to us and are required by Health
Education England and the regional London Local Education and Training Boards.
1.
Four study days with 6 hours teaching evaluated as too long and too much information on each day.
Course lengthened to 5 study days of 4-5 hours.
2.
Assignment changed to avoid unintended plagiarism
16