9&10&11

Question 1

What is evidence-based decision making (EBDM)?

Answer 1

Process for identifying and using most up-to-date (and relevant) evidence to inform
decisions for individual patient problems.

Question 2

What does EBDM involve?

Answer 2

 Patient preferences
 Available resources
 Research evidence
 Clinical expertise

Question 3

Why is decision making in medicine important?

Answer 3

 Doctors make decisions constantly
 The decisions have effects on patients, families, and society
 An understanding of decision making, and the role of evidence, can help improve medical practice

Question 4

Why do we need EBDM?

Answer 4

 Limited time to read
 Inadequacy of ‘traditional’ sources of information - text books often out of date
 Disparity between diagnostic skills/clinical judgement (which increase over time) and
up-to-date knowledge/clinical performance (which decrease).

Question 5

What are the 6 types of research papers?

Answer 5

 Cohort study
 Case control
 Qualitative
 Randomised control trials
 Diagnostic and screening
 Systematic reviews

Question 6

What is the 5 process of EBDM?

Answer 6

1. Identifying the need for information
2. Identifying the best evidence
3. Critically appraising the evidence
4. Integrating the critical appraisal to clinical expertise
5. Evaluating and seeking ways to improve.

Question 7

What are the two types of questions in EBM?

Answer 7

 Foreground question
 Background question

Question 8

What is a background question?

Answer 8

Generalised and usually formed off our own experience. Has two parts to it a ROOT and Disorder

Question 9

What is a foreground question?

Answer 9

More specific and detailed question about managing patients with a disorder.
Uses PICO

Question 10

What does PICO stand for?

Answer 10

 P- Patient
 I- Intervention
 C- Comparative intervention
 O- Outcome clinically

Question 11

What are the 4 steps in the approach to smoking cessation?

Answer 11

1. Health education and general information to enhance motivation for quitting (light
   smokers)
2. Brief advice from a health professional to quit smoking (light smokers)
3. Advice, nicotine replacement, follow-up by a specialist (moderately motivated,
   medium dependence smokers)
4. Specialised counselling rooms and agencies working with group sessions (highdependent smokers)

Question 12

What is antibiotic resistance?

Answer 12

 Bacteria change so antibiotics no longer work in people who need them to treat
infections

Question 13

What are the reasons for the widespread use of antibiotics?

Answer 13

 Increase in global availability
 Uncontrolled sale in many low or middle income countries

Question 14

What are some of the causes of antibiotic resistance?

Answer 14

 Use in livestock for growth promotion
 Releasing antibiotics into the environment during pharmaceutical manufacturing
 Volume of antibiotic prescribes
 Missing doses when taking antibiotics
 Inappropriate prescribing of antibiotics

Question 15

How can antibiotic resistance be prevented?

Answer 15

 Using antibiotics only when prescribed by a doctor
 Completing the full prescription
 Never sharing antibiotics or using leftover prescriptions
 Only prescribing antibiotics when they are needed
 Using the right antibiotics to treat the illness

Question 16

Which factors influence infection?

Answer 16

 Infectious agents - Ability to reproduce, survival, ability to spread, infectivity,
pathogenicity
 Environment - Contamination, other humans, animals, water
 Mode of transmission - Droplet, airborne, aerosol, direct consumption, fecal-oral
route, blood bourne, sexual contact, zoonosis
 Portal of entry - Mouth, nose, ears, genital tract, skin
 Host factors - Chronic illness, nutrition, age, immunity, lifestyle (e.g. smoking, drugs
etc)

Question 17

what healthcare associated infections are on mandatory surveillance?

Answer 17

c diff, MRSA bacteraemia, MSSA bacteraemia

Question 18

what are the most common Healthcare associated infection?

Answer 18

 C. diff, UTI, Pneumonia most common

Question 19

What are the most important infectious diseases in developing countries?

Answer 19

Pneumonia, chronic diarrhoea, malaria, HIV/AIDS

Question 20

What is surveillance?

Answer 20

Systematic collection, collation and analysis of and Publication of data so that appropriate control measures can be taken

Question 21

What is the purpose of surveillance?

Answer 21

 Serve as an early warning system for impending public health emergencies
 Document the impact of an intervention, or track progress towards specific goals
 Monitor and clarify the epidemiology of health problems, to allow priorities to be set .

Question 22

What can be done to reduce the risk of nosocomical infections?

Answer 22

 Prevention - Hand washing, sterilisation and decontamination of instruments
 Detection, investigation and control of outbreaks
 Policies and procedures to prevent and control infection
- Education and training

Question 23

What is global health?

Answer 23

Global health refers to the health of the world’s population and it aims to improve health and achieve health equality worldwide.

Question 24

What is international health?

Answer 24

 Health defined by geography (poor nations), problems (infections, water, sanitation),
instruments (infection control, aid) and a recipient and donor relationship

Question 25

What are the major functions of global health?

Answer 25

 To provide health-related public goods
 To manage cross-national externalities through epidemiological surveillance,
information sharing, and coordination
 To mobilise global solidarity for populations facing deprivation and disasters

Question 26

What is the motivation for global health?

Answer 26

 Increased awareness of global health disparities
 Enthusiasm to make a difference across international boundaries

Question 27

What is the ‘90/10 gap’ (commission on health research for development - 1990)?

Answer 27

Less than 10% of worldwide resources devoted to health research were put towards
health in developing countries, where over 90% of all preventable deaths worldwide
occurred.

Question 28

What is the solution for this 10/90 gap?

Answer 28

 Regulation of imported goods
 Getting timely access to information about the global spread of infectious diseases
 sufficient vaccine and drug supplies in a pandemic
 Ensuring a sufficient body of well-trained health personnel

Question 29

What impact has travel and migration had on diseases seen in the UK?

Answer 29

 Help spread infectious diseases
 Transmission of behaviour and culture increases risk of non-communicable diseases
 May introduce a diseases to a new population - Widespread and deadly effects
 More in contact with animals - Increase in animal diseases (zoonosis)
 Migrants may bring diseases to countries that have not been exposed

Question 30

What is WHOs definition of environment, in relation to health?

Answer 30

• All the physical, chemical and biological factors external to a person, and all the
  related behaviours
   Environmental health consists of preventing or controlling disease, injury, and
  disability related to the interactions between people and their environment

Question 31

What is an outbreak?

Answer 31

an epidemic limited to localised increase in disease incidence.

Question 32

What is an epidemic?

Answer 32

occurrence in a community/region of cases of an illness/health-related behaviour clearly in excess of normally expected.

Question 33

What is a pandemic?

Answer 33

Epidemic over a very wide area, crossing international boundaries

Question 34

3 ways we can prevent epidemics?

Answer 34

• Funds and international responders sent to country with outbreak to reduce human suffering
• Development of vaccines
• Monitor disease to prevent future outbreaks

Question 35

What are four roles of WHO in public health?

Answer 35

• Provide leadership on matters regarding health.
• Setting norms and standards by promoting and monitoring their implementation
• Articulating ethical and evidence-based policy options
• Monitoring the health situation and assessing health trends

Question 36

What general intervention strategies are possible for HIV/AIDS?

Answer 36

 Introduction of blood donor and product screening
 Promotion and distribution of condoms at affordable prices
 Peer education for high risk groups e.g. sex workers
 Promotion of safer sexual behaviour at the population level
 Diagnosis and treatment of STDs
 HIV voluntary counselling and testing

Question 37

What are the current problems and issues surrounding global health?

Answer 37

 Africa struggles against debt, trade restrictions and inadequate aid provisions
 Global fund in under-resourced
 US politics are retrogressive and harmful

Question 38

What are the public health objectives of vaccination?

Answer 38

 To reduce mortality and morbidity from vaccine preventable infections
 To prevent outbreaks and epidemics
 To contain an infection in a population
 To reduce the number of infections
 To interrupt transmission to humans
 To generate herd immunity
 To eradicate an infectious agent

Question 39

What factors influence the utility of immunisation/vaccination as an approach to disease
prevention?

Answer 39

 Disease burden
 Risk of exposure to the disease
 Age, health status, vaccination history
 Special risk factors
 Reactions to previous vaccine doses, allergies
 Risk of infecting others
 Cost
 Are there other ways to control the disease?
 impact on public perception

Question 40

What is required for a disease to be eradicated using vaccination?

Answer 40

• Where there are no other reservoirs of the infection to exist in animals or environment
• consequences of infection need to be very high
• needs to be scientific and political prioritisation

Question 41

Give examples of diseases that have been eradicated?

Answer 41

 Smallpox
 Polio

Question 42

What is herd immunity?

Answer 42

 Level of immunity in the population which protects the whole population
 Herd immunity only applies to diseases which are passes from person to person
 Provides indirect protection to unvaccinated as well as direct effect to the vaccinated
 A disease can therefore be eradicated even if some people remain susceptible

Question 43

What is R0?

Answer 43

• Basic reproduction rate
• The average number of individuals directly infected by an infectious case during the infectious period, in a totally susceptible population

Question 44

What factors affect R0?

Answer 44

 The rate of contacts in the host population
 The probability of infection being transmitted during contact
 The duration of infectiousness

Question 45

What is effective reproduction rate (R)?

Answer 45

estimation of the average number of secondary cases per infectious case in a population . Includes both susceptible and non-susceptible hosts

Question 46

What is the equation for effective reproduction rate?

Answer 46

 R = R0x (x is the fraction of the host population which is susceptible e.g. half
population is 0.5)
 R>1 - number of cases increases
 R<1 - Number of cases decreases, needs to be maintained for elimination
 R=1 - Epidemic threshold

Question 47

What is the equation for herd immunity?

Answer 47

 H = (R0-1)/ R

Question 48

What is a susceptible population?

Answer 48

Any person who is not immune to a particular pathogen is said to be susceptible
 A person may be susceptible because they have never encountered the infection or
the vaccine against it before
 A person may be susceptible because they are unable to mount an immune response
 A person may be susceptible because vaccination is contraindicated for them

Question 49

What is WHOs role in vaccination?

Answer 49

 Makes recommendations for countries on vaccination policy
 Supports less able countries with vaccination strategy implementation
 International health regulations to ensure the maximum security

Question 50

List some international immunisation programmes?

Answer 50

 Expanded programme on Immunisation (EPI)
 Global Polio Eradication Initiative (GPEI)
 Global Alliance for Vaccines and Immunisation (GAVI)

Question 51

How are new vaccination programmes implemented - Why, how and when?

Answer 51

 Why - To protect vulnerable, contain outbreak, eradicate disease
 How - Pilots, phased introduction, global vaccination
 When - Greatest impact on disease burden

Question 52

What is shared decision making and why is it important?

Answer 52

 Conversation between patient and their health care professional to reach a health
care choice together.
 Important when - There is more than one reasonable option, no one option has a
clear advantage, the possible benefits/harms of each option affect patients
differently

Question 53

What are the pros of vaccination?

Answer 53

 Can save life
 Ingredients are safe in the amount used
 Adverse reactions are rare
 Herd immunity
 Save children and parents time and money
 Protect future generations
 Eradication of diseases
 Economic benefits for society

Question 54

What are the cons of vaccination?

Answer 54

 Can cause serious and sometimes fatal side effects
 Contain harmful ingredients
 Government should not intervene in personal medical choices
 Can contain ingredients some people object to e.g. chicken eggs
 Unnatural
 Pharmaceutical companies main goal is to make profit
 Some diseases that vaccines target are relatively harmless in many cases e.g.
rotavirus

Question 55

What factors influence decision making?

Answer 55

 Lifestyle
 Perception of health
 Beliefs about childhood diseases
 Risk perception of the diseases
 Perceptions about vaccine effectiveness and vaccine components
 Trust in institution

Question 56

What is the population vs individual interest debate?

Answer 56

 For the individual - Protection by ‘herd immunity’ may be safest option as avoids risk
of vaccine
 For the community - Avoidance of vaccination leads to reduced coverage so
diminishes herd immunity

Question 57

Which websites can be used to find out if a person needs travel vaccines?

Answer 57

 NHS fitfortravel
 The National Travel Health Network and Centre (NaTHNaC)

Question 58

What are some of the free and private travel vaccines available?

Answer 58

 Free - Diptheria, polio, tetanus, typhoid, hepatitis A, cholera
 Private - Hepatitis B, japanese encephalitis, meningitis, rabies, TB, yellow fever

Question 59

What factors should be considered when deciding to get travel vaccinations?

Answer 59

 The country or countries you’re visiting
 When you’re travelling
 Where you’re staying
 How long you’ll be staying
 Your age and health
 What you’ll be doing during your stay
 If you’re working as an aid worker
 If you’re working in a medical setting
 If you’re in contact with animals

Question 60

What are the 5 most common cancers (incidence) in adult men and women in the UK (list
in order)?

Answer 60

1. Breast/prostate
2. Lung
3. Bowel
4. Melanoma
5. Non-Hodgkin Lymphoma

Question 61

What are the 5 most common causes of cancer mortality for adult men and women
combined in the UK (list in order)?

Answer 61

1. Lung
2. Bowel
3. Prostate/breast
4. Pancreas
5. Oesophagus

Question 62

What are the most common cancers in children?

Answer 62

 Leukemias

Question 63

What is the most common causes of cancer mortality in children?

Answer 63

 Brain, CNS and intracranial tumours

Question 64

How do the patterns of cancer in the UK differ from that seen in a developing country?

Answer 64

 Mortality is higher in UK (29%)

Question 65

What is the role of legal and lifestyle changes in reducing incidence and mortality of
cancer?

Answer 65

 Prevention - Legal and lifestyle changes, vaccinations
 Screening - Early detection and diagnosis
 Disease management - Improving treatments and quality of life

Question 66

What is meant by difficult (or bad) news?

Answer 66

Bad/difficult news is defined as any news that drastically and negatively alters the
patient’s (or their relatives) view of his or her future

Question 67

What factors can affect the impact of good/bad news on a patient?

Answer 67

Institutionalised beliefs, personality types, gender, culture/race, religion, patients
knowledge, relatives

Question 68

What anxieties might health care professionals have about breaking bad news?

Answer 68

 Uncertainty about the patient’s expectations
 Fear of destroying the patient’s hope
 Fear of their own inadequacy in the face of controlling disease
 Not feeling prepared to manage the patients anticipated emotional reactions
 Embarrassment at having previously painted too optimistic a picture for the patient

Question 69

What is the ABCDE method of breaking bad news?

Answer 69

 A - Advanced preparation
 B - Building a relationship
 C - Communicate well
 D - Deal with patient reactions
 E - Encourage and validate emotions

Question 70

What is the SPIKES method of breaking bad news?

Answer 70

 S - Setting up
 P - Perception
 I - Invitation
 K - Knowledge
 E - Emotions
 S - Strategy and summary

Question 71

What emotions may a patient feel when they receive difficult news?

Answer 71

 Grief, distress, denial, anger, agitated/restless

Question 72

How can cancer change partner relationships?

Answer 72

 Change in roles
 Change in responsibilities
 Change in physical needs
 Change in emotional needs
 Change in sexuality and intimacy
 Change in future plans

Question 73

What were the conclusions and consequences of the Eurocare-II report?

Answer 73

 Despite limitations of the methodology, cancer survival in the UK in the 1980-90s
was one of the worst in Europe
 Expert advisory group formed to the chief medial officer in 1995 which generated
the calman-hine report

Question 74

What were the 6 conclusions and consequences of the Calman-Hine report (1995)?

Answer 74

Conclusion: Proposed a restructuring of cancer services. by:
- uniformly high quality of care
- Public and professional education to recognise early symptoms of cancer
- Patients, families and carers should be given clear information about treatment options and outcomes
- The development of cancer services should be patient centred
- Primary care to be central to cancer care
- The psychosocial needs of cancer sufferers and carers to be recognised

Question 75

What are the Calman-Hine solutions?

Answer 75

 There should be 3 levels of care:
 Primary care
 Cancer units serving district general hospitals - Treat common cancers,
diagnostic procedures, common surgery, non-complex chemo
 Cancer centres (populations in excess of 1 million) - Treat rare cancers,
radiotherapy, complex chemo
 Key to managing patients would be the MDT

Question 76

What is a national service framework?

Answer 76

 Sets national standards and defines service models for a service or care group
 places programs to support implementation
 Establish performance measures

Question 77

What are the four main aims of the NHS cancer plan (2000)?

Answer 77

 Save more lives
 Ensure people with cancer get the right professional support, care and treatments
 Tackle the inequalities in health
 Build for the future - Investment in cancer workforce, strong research

Question 78

What are the 6 key areas for action in the cancer reform strategy (2007)?

Answer 78

 Prevention
 Diagnosing cancer earlier - Screening
 Ensuring better treatment - Reduced waiting times
 Living with and beyond cancer - National cancer survivorship initiative
 Reducing cancer inequalities
 Delivering care in the most appropriate setting - centralised where necessary

Question 79

Which cancers are screened for?

Answer 79

 Cervical, breast and bowel

Question 80

What is the national cancer survivorship initiative?

Answer 80

 Partnership with cancer charities, clinicians and patients, considered a range of approaches to improving services and support available for cancer survivors

Question 81

What were the four main outcomes from ‘Improving outcomes: A strategy for cancer (2011)’?

Answer 81

 Prevention and early diagnosis - Focus on lifestyle factors, screening, diagnostic tests
 Quality of life and patient experience - Patient experience surveys, more 1-1 support
roles,
 Better treatments
 Reducing inequalities

Question 82

What are some of the inequalities experiences amongst cancer patients?

Answer 82

 White cancer patients report a more positive experience than other ethnic groups
 Younger people are the least positive about their experience, particularly around
understanding completely what was wrong with them
 Men are generally more positive about their care than women, particularly around
staff and staff working together
 Non-heterosexual patients reported less positive experience, especially in relation to
communication and being treated with respect and dignity
 People with rarer forms of cancer in general reported a poorer experience of their
treatment and care than people with more common forms of cancer

Question 83

What are 4 outcomes from the independent cancer taskforce (2015)?

Answer 83

• radical upgrade in prevention and public health
• Drive a national ambition to achieve earlier diagnosis
• Transform our approach to support people living with and beyond cancer
• Make the necessary investments required to deliver a modern high-quality service

Question 84

What is body image?

Answer 84

 Perceptions, thoughts, and behaviours related to one’s appearance
 The body is a bearer of values and a means of representing our identity to others - It
shows who we are to others

Question 85

What is biographical distribution?

Answer 85

 Chronic illness leads to a loss of confidence in the body
 From this follows a loss of confidence in social interaction or self-identity

Question 86

Give examples of diseases/symptoms/treatments/side-effects which affect body image?

Answer 86

 Scars
 Prosthetic device - leg
 Mastectomy
 Impact on sexuality - Function, pain, appearance
 Stoma
 Hair loss
 Weight loss/weight gain

Question 87

What is the importance of hair?

Answer 87

 An important site for individual and group identity
 A way of ‘doing gender’ - A symbol of femininity? Hair loss not so bad for men
 Stigma - Patients have some choice as to whether they will be stigmatised
 Patient control of their status as sick - Can be managed through ‘normal’ appearance
(wigs, beanies, scarves)

Question 88

What are the functions of the clinical record?

Answer 88

 Support patient care
 Improve future patient care
 Social purposes at the request of patients
 Medico-legal document

Question 89

What should be recorded in a clinical record?

Answer 89

 Presenting symptoms and reasons for seeking health care
 Relevant clinical findings
 Diagnosis and important differentials
 Options for care and treatment
 Risk and benefits of care and treatment
 Decisions about care and treatment
 Action taken and outcomes

Question 90

What are the differences between paper and electronic records?

Answer 90

 Paper - Continuous, portable, writer identified, legibility issues, must be dated and
signed
 Electronic - Problem orientated, searchable, structured, safer prescribing, clinical
decision support software

Question 91

What is the use of records in audit, research and management?

Answer 91

 Support clinical audit
 Facilitates clinical governance
 Facilitates risk management
 Support clinical research

Question 92

What is duty of care?

Answer 92

 Legal obligation which is imposed on an individual requiring adherence to a standard of reasonable care while performing any acts that could foreseeably harm others

Question 93

What is negligence?

Answer 93

 Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances
 You have to make decisions that adheres to your duty of care as a doctor and could
not be considered negligent

Question 94

What are the 4 ethical principles?

Answer 94

 Beneficence - Duty to do good
 Non-maleficence - Duty to not cause harm
 Autonomy - Patient has the right to make their own decision
 Justice - Fair, equitable treatment for all

Question 95

What are the ethical theories?

Answer 95

 Consequentialism - The correct moral response is related to the outcome or consequence of the act
 Deontology - Places value on the intentions of the individual and focuses on rules, obligations and duties
 Virtue ethics - Right living is derived from the moral character of the agent

Question 96

How do you evaluate an argument?

Answer 96

1. Get clear on the logical form of the argument
2. Query - Valid and sound

Question 97

4 reasons Why an argument be invalid?

Answer 97

 Different premises may express different concepts
 Confusing necessary with sufficient, and vice-versa
 Insensitive to the way in which claims are qualified
 Argument begs the question

Question 98

Why might an argument be unsound?

Answer 98

 Argument is invalid
 Argument is valid but one or more premise is false - Makes a false/controversial, moral/empirical claim
 An unsound argument doesn’t mean there will be an unsound conclusion

Question 99

What should be avoided in arguments?

Answer 99

 Straw man fallacy - Simply ignoring the person’s actual position and substituting it for a distorted, exaggerated or misrepresented version of that position
 Ab hominems - Directed against a person rather than the position they are
maintaining
 Appealing to emotion
 Begging the question

Question 100

What is a moral argument?

Answer 100

 Seek to support a moral claim of some kind.
 Argument need not succeed but to be an argument it must at least provide some supporting reasons for the claim in question

Question 101

What is a deductive argument?

Answer 101

 Purely logic
 This means this, therefore this means this

Question 102

What is an inductive argument?

Answer 102

 Making an argument based on observation, more probable conclusions (seeing is
believing but you may not have seen everything)

Question 103

What are MDTs in cancer care and why are they needed?

Answer 103

 Allows Modern management of cancer
 Allied health professionals
 Allows delivery of cancer care to sometimes be fragmented over several hospital sites.
 Better outcomes for patients managed in MDTs

Question 104

Who is in a cancer MDT (core and extended)?

Answer 104

Core (medical staff):
 Physicians
 Surgeons
 Oncologist
 Radiologist
 Histopathologist
 Specialist nurses
 MDT co-ordinator
Extended:
 Physiotherapist
 Dietician
 Palliative care
 Chaplin

Question 105

What are the functions of MDTs in cancer care?

Answer 105

 Discuss every new diagnosis of cancer within their site
 Decide on a management plan for every patient
 Inform primary care of that plan
 Designate a key worker for that patient
 Develop referral, diagnosis and treatment guidelines for their tumour sites
 Audit

Question 106

What is sensitivity?

Answer 106

 True positives
 Measures the proportion of positives that are correctly identified

Question 107

What is the equation for sensitivity?

Answer 107

Sensitivity= True positive / True positive + False negative

Question 108

What is specificity?

Answer 108

 True negatives
 Measures the proportion of negatives that are correctly identified

Question 109

What is the equation for specificity?

Answer 109

Specificity= True negative/ True negative + False positives

Question 110

What is a diagnostic test?

Answer 110

 Any kind of medical test performed to aid the diagnosis or detection of disease

Question 111

What are the uses of diagnostic tests?

Answer 111

 Diagnosis
 Monitoring
 Screening
 Prognosis

Question 112

How is sensitivity and specificity important in informing diagnosis?

Answer 112

diagnostic accuracy in testing is important as its directly proportional to the tests potential to cause patient consequence and harm.

Question 113

What does true positive mean?

Answer 113

 Test indicates disease when there is disease

Question 114

What does true negative mean?

Answer 114

 Test indicates no disease when there is no disease

Question 115

What does false positive mean?

Answer 115

Test indicates disease when there is no disease

Question 116

What does false negative mean?

Answer 116

 Test indicates no disease when there is disease

Question 117

What is positive predictive value?

Answer 117

 The probability that subjects with a positive screening test truly have the disease

Question 118

What is negative predictive value?

Answer 118

 The probability that subjects with a negative screening test truly don’t have the
disease.

Question 119

What is the likelihood ratio?

Answer 119

The probability that someone with the disease has a particular test result compared to someone without the disease

Question 120

What is screening?

Answer 120

Systematic application of a test to identify individuals at sufficient risk of a specific disorder to warrant further investigation.

Question 121

What is the purpose of screening?

Answer 121

 Opportunities for primary prevention are limited
 Opportunities for treatment are limited
 Screening gives potential for early and more effective treatment

Question 122

What is commonly screened for?

Answer 122

 Cancer - Colorectal cancer, Breast cancer, Cervical cancer
 PPD test - Tuberculosis
 Prenatal tests - Foetal abnormalities
 Newborn bloodspot test - PKU, cystic fibrosis etc
 Ophthalamoscopy or digital photography and image grading - Diabetic retinopathy
 Ultrasound scan - Abdominal aortic aneurysm
 Screening for metabolic syndrome
 Screening for potential hearing loss in newborns

Question 123

What are the limitations ( disadvantage) of screening?

Answer 123

 Cost and use of medical resources on a majority of people who do not need treatment
 Adverse effects of screening procedure - Stress, anxiety, discomfort, radiation exposure
 Stress and anxiety caused by a false positive result
 Unnecessary investigation and treatment of false positive results
 Stress and anxiety caused by prolonging knowledge of an illness without any improvement in outcome
 A false sense of security caused by false negatives, which may delay final diagnosis

Question 124

What are the pros and cons of good screening?

Answer 124

 Pros - Early detection of disease means the risk of death or illness can be reduced for some people.
 Cons - Some people get tests, diagnosis and treatment with no benefit. Some people get ill or die despite a negative screening test.

Question 125

What areas should be evaluated when deciding what should be screened for?

Answer 125

 Condition - Important? epidemiology, natural history of condition, detectable risk
factor, latent period, cost-effective
 Test - Simple, safe, precise, validated
 Treatment - Effective evidence based treatment
 Programme - RCT evidence of reduction in mortality or morbidity, opportunity cost

Question 126

What is sojourn time?

Answer 126

 The duration of a disease before clinical symptoms become apparent but during which it is detectable by a screening test.
 Its clinical relevance is that it represents the duration of the temporal window of opportunity for early detection.
 Length of sojourn time short - Rapidly progressing disease, poorer prognosis
 Length of sojourn time long - Better prognosis

Question 127

What is length bias?

Answer 127

 Overestimation of survival duration among screening-detected cases by the relative excess of slowly progressing cases

Question 128

What are the consequences of length bias?

Answer 128

Diseases with a longer sojourn time are ‘easier to catch’ in the screening net.
 On average, individuals with disease detected through screening ‘automatically; have a better prognosis than people who present with symptoms/signs.
 If we simply compare individuals who choose to be screened with those who didn’t we will get a distorted picture

Question 129

What is lead time bias?

Answer 129

 Overestimation of survival duration among screen-detected cases, when survival is measured from diagnosis.

Question 130

What are the consequences of lead time bias?

Answer 130

Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time. So even though treatment is not effective and they will still die because its diagnosed earlier it looks like they have lived longer.

Question 131

What is overdiagnosis bias?

Answer 131

Overestimation of survival duration among screen-detected cases caused by inclusion of pseudodisease.
BASICALLY
A diagnosis of a medical condition that would have never caused the patient any problems or symptoms during their lifestyle.

Question 132

What is PSA testing and what can caused elevated PSA?

Answer 132

 Prostate-specific antigen (PSA) - protein produced by cells of the prostate gland
 Elevated in - Prostate cancer, BPH, prostatis, UTI

Question 133

What are the four advantages of PSA screening?

Answer 133

 Can help detect tumours with no symptoms
 Allows estimation of prostate size and stage
 Helps doctor predict response to treatment
 Can be used to monitor men who are at increased risk

Question 134

What are the disadvantages of PSA screening?

Answer 134

 Early detection may not reduce the chance of dying from prostate cancer
 Overdiagnosis -> overtreatment
 May give false-positive - Other conditions can increase PSA, not specific enough
 May give false-negative

Question 135

What are some of the impacts that incontinence might have on a patient?

Answer 135

 Distress
 Embarrassment
 Inconvenience
 Threat to self esteem
 Loss of personal control
 Desire for normalisation
 loss of interest in sex
 Difficulty sleeping (especially with nocturia)

Question 136

What impact might chronic dialysis have on a patient?

Answer 136

 Regular hospital admissions
 Restriction of leisure time
 May have to give up job
 Increased dependence on dialysis
 Uncertainness about the future
 Fatigue
 Limitation of liquids and foods
 Disrupts family and friend relationships
 Depression
 Lower self-esteem

Question 137

What 4 sources are used when making a Evidence based (clinical) decision?

Answer 137

 Patient preferences
 Available resources
 Research evidence
 Clinical expertise

Question 138

What is opportunity cost?

Answer 138

Next best alternative forgone

Question 139

What is distributive justice?

Answer 139

How we distribute resources that are finite in a fair way

Question 140

How can you decide ways to distribute healthcare?

Answer 140

 QALY calculation
 Waiting list
 Likelihood of complying with treatment
 Lifestyle choices of patient
 Ability to pay

Question 141

What is confidentiality?

Answer 141

 Pledge of agreement to not divulge or disclose information about patients to others

Question 142

Why is it important to maintain confidentiality

Answer 142

 Improves trust between patient and doctor
 Respects autonomy
 Prevents patient harm
 Virtuous
 Human rights act
 GMC requirement

Question 143

When can confidentiality be breached?

Answer 143

 Statute (law)
 Consent by patient
 Public best interest

Question 144

Name some statutes (laws) that oblige doctors to disclose information?

Answer 144

 Public Health Act 1984
 Road Traffic Act 1988
 Prevention of terrorism act 1989

Question 145

what does the human rights act 1998 establish?

Answer 145

article 8 establishes right to ‘respect for private and family life’

Question 146

what is Gillick competence and when can it be broken?

Answer 146

Consent of U16 with sufficient understanding must be respected (+ refusal)  but can be broken if duty of care in case of life threatening results/condition (i.e. kid with CLL refuses chemo)

Question 147

what does the mental capacity act 2005 state?

Answer 147

Assumes competence of >18, defines how to assess it, best interest.

Question 148

what is common/case law?

Answer 148

 info shouldn’t be disclosed further than originally understood by confider, unless with subsequent permission.

Question 149

What is puerperium?

Answer 149

• Postnatal period
• Period of about 6-8 weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition

Question 150

What was the main outcome of the Peel Committee Report (1970)?

Answer 150

Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital

Question 151

What was the outcome of the Midwives’ Act (1902)?

Answer 151

• Established normality in childbearing as the midwife’s role - refer to doctors as soon as abnormality occurs
• This ensures equal access to midwives and doctors for childbearing women of all socioeconomic standing

Question 152

How can falls be prevented/decrease risk?
(6 ways)

Answer 152

• Increase activity - diversity of physical activity
• Weekly walk for exercise
• Strong family networks
• Multifactorial falls risk assessment
• Multifactorial intervention
• Education and information

Question 153

What does the NICE guidelines state about acupuncture in lower back pain, osteoarthritis, and headaches?

Answer 153

• Lower back pain - consider manual therapy, do not offer acupuncture
• Osteoarthritis - manipulation and stretching should be considered as an adjunct to core treatments, do not offer acupuncture
• Headache/migraine - consider a course of up to 10 sessions of acupuncture over 5-8 weeks

Question 154

What are the cons of advanced directives?

Answer 154

• Difficulty to verify if the patient’s opinion has changed since making AD
• Difficult to ascertain whether the current circumstances are what the patient foresaw when making AD
• Possibility of coercion on behalf of the patient
• Possible wrong diagnosis
• Can patients imagine future situations sufficiently and vividly enough to make their current decisions adequately informed?

Question 155

What is asbestos?

Answer 155

• A natural occurring silicate mineral
• Used a lot in the 1950s-60s as a building material - fire retardant and could be used as cement
• In the 1960s it was found to cause malignant mesothelioma (pleural tumour) - only a small amount of asbestos was found to cause this

Question 156

Where is the preferred place of death?

Answer 156

Preferred place of death is difficult as most people dont know when it will happen.
- Most people wish to die at home
- Few people wish to die in hospital But Most people end up dying in hospital

Question 157

What do systematic reviews look at?

Answer 157

A systematic review is the highest level of evidence. It looks at all available evidence and combines the results to determine what the evidence says overall in a meta analysis.

Question 158

What is the purpose of the 6-8 week postnatal check?

Answer 158

• Take history
• Assess psychological and social situation
• Examination of mother - abdomen, vaginal exam (sometimes), BMI
• Examination of baby - weight, head circumference, appearance and movement, hips, heart, spine, eyes
• Health promotion - immunisations, breast-feeding, reducing risk of SIDS, car safety
• Assessment of parenting and emotional attachment

Question 159

What is the research cycle?

Answer 159

1. Identify a clinical problem
2. Basic research - laboratory based
3. Applied (clinical) research
4. Clinical care

Question 160

What is the main risk factor associated with increased risk of fracture?

Answer 160

Osteoporosis

Question 161

How many people in the world are infected with TB?

Answer 161

1/4 affected with Tb worldwide, which is approximately 2 billion

Question 162

How many deaths per year does TB cause (million)?

Answer 162

1.5 million people (in 2020 according to WHO)

Question 163

What are some examples of occupational lung disease?

Answer 163

• Occupational asthma
• COPD
• Pneumoconiosis
• Toxic pneumonitis
• Hypersensitivity pneumonitis
• Benign pleural disease
• Infections including TB
• Malignancy of lung and pleura

Question 164

What are the 2 types of asbestos fibres?

Answer 164

• Serpentine - curly, white asbestos (relatively harmless), cleared with mucociliary escalator
• Amphiboles - short, sharp, blue/brown asbestos (have malignant potential)

Question 165

What is decision analysis?

Answer 165

Systematic and quantitative way of making healthcare decisions e.g. when presented with two options

Question 166

What are some toxins that cause food poisoning?

Answer 166

• Bacterial toxins - clostridium perfringens, s. aureus, clostridium botulinum
• Marine biotoxins - scombroid poisoning, shellfish, ciguatera

Question 167

What are the arguments for and against age-based rationing being applied to micro-level resource allocation decisions?

Answer 167

• For - age should be relevant because older people are less likely to respond to treatment and have a poorer prognosis in general due to increased complication risk
• Against - age alone is not a good predictor of prognosis/complications hence need case-by-case decisions, decisions based on age may be hidden form of discrimination

Question 168

Define patient safety

Answer 168

Coordinated efforts to prevent harm to patient caused by the process of healthcare itself

Question 169

What is an adverse event?

Answer 169

Unintended event resulting from clinical care and causing patient harm

Question 170

What is a near miss?

Answer 170

A situation in which events or omissions arising during clinical care fail to develop further

Question 171

Describe the Swiss cheese model of accident causation

Answer 171

Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur

Question 172

What are the main causes of error at an individual and a system level?

Answer 172

• Individual error - errors of individuals, blames individual for forgetfulness, inattention or moral weakness
• System error - conditions under which an individual works, tries to build defences to eliminate errors or mitigate their effect

Question 173

What are active failures?

Answer 173

• Unsafe acts committed by people in direct contact with the patient
• Usually short lived, often unpredictable

Question 174

What is latent error?

Answer 174

They are intrinsic to a system and are things in background which ↑likelihood of mistakes being made.
-Develop over time and lay dormant until combine with other factors and cause an adverse event

Question 175

What are the different types of errors? (3 types)

Answer 175

• Knowledge based error - Forming wrong intentions or plans due to inadequate knowledge/experience
• Rule based error - Encountering relatively familiar problems but applying wrong rule, either misapplication of a good rule or application of a bad rule
• Skills based error- attention slips and memory lapses, involve the unintended change of actions from what may have been a good plan; people are prone to these types of errors, mainly due to interruption or distraction

Question 176

What are violations?

Answer 176

• Deliberate deviation from some regulated code of practice or procedure
• They occur because people intentionally break the rules

Question 177

What are the types of violation? (4 types)

Answer 177

• Routine - regularly performed shortcuts due to system, process or task being poorly designed; may become accepted practice over time
• Reasoned - occasional reasoned deviation from a protocol which we believe we have good reason for making (e.g. time constraints), may be in patient’s best interests
• Reckless - deliberate deviations from a protocol and include acts where opportunity for harm is foreseeable and ignored, although harm may never be intended.
• Malicious - deliberate deviations from a protocol, where the intention is to cause harm.

Question 178

What systems are in place in the NHS to try and prevent errors occurring? (3 systems)

Answer 178

• National Patient Safety Agency (NPSA) 2001 - coordination of reporting and learning from mistakes that affect patient safety
• National Reporting and Learning System (NRLS) 2004 - national system for anonymous reporting go patient safety incidents,
• Medicines and Healthcare Products Regulatory Agency (MHRA) - ensures medicines, healthcare products and medical equipment meet appropriate standards of safety.

Question 179

How do we know if a hospital is safe?

Answer 179

• Hospital mortality data
• Data on other measures of safety - reports of never events and serious incidents, NHS safety thermometer, patent safety dashboards.
• Monitoring and inspections by regulators - care quality commission (CQC), NHS Improvement.

Question 180

What situations are associated with an increased risk of error? (6 examples)

Answer 180

• Unfamiliarity with the task
• Inexperience
• Shortage of time
• Inadequate checking
• Poor procedures
• Poor human equipment interface

Question 181

What should we do when adverse incidents occur? (5 steps)

Answer 181

• Report it - incident reporting systems
• Assess its seriousness
• Analyse why it occurred - root cause analysis
• Be open and honest with the affected patient and apologise - duty of candour
• Learn from the event and put in place action to reduce risk of repeat

Question 182

Why do children go to A&E?

Answer 182

• Accidental injury
• Asthma
• Respiratory illness
• Infective process
• Rashes
• Appendicitis

Question 183

Why are males more likely to die than females?

Answer 183

• Higher suicide rates
• Violence related incidents
• Road traffic accidents
• Behavioural differences between males and females - more likely to take part in ‘risky’ behaviour

Question 184

What is the most common cause of external deaths in adolescents?

Answer 184

Traffic accidents (>50%)

Question 185

Why does poverty increase the chance of getting ill?

Answer 185

• Poor nutrition
• Overcrowding
• Lack of clean water
• Harsh realities that may make putting your health at risk the only way to survive or keep your family safe

Question 186

Why does poor health increase poverty?

Answer 186

• Reducing a family’s work productivity
• Leading family to sell assets to cover the costs of treatment

Question 187

What are the implications of chronic illness in children?

Answer 187

• Affects physical, mental and social development
• Repeated absence at school
• Affect on parents and siblings
• Financial effect (family and community)
• Can be lifelong

Question 188

What conditions are screened for before birth? (3 main tests)

Answer 188

Antenatal screening tests identify major abnormalities
- Alpha fetoprotein - raised in neural tube defects and some GI abnormalities
- Downs test - alpha fetoprotein and HCG
- Ultrasound - growth check, cardiac abnormalities, diaphragmatic hernia

Question 189

What tests are done neonatally? (2 tests)

Answer 189

• Blood spot test - PKU, cystic fibrosis, sickle cell disease, congenital hypothyroidism
• Physical examination

Question 190

What are the timings for screening and developmental surveillance?

Answer 190

• Antenatal screening (12th week of pregnancy)
• Neonatal examination
• New baby review (14 days)
• 6-8 week check
• 1 year check
• 2-2.5 year check

Question 191

What is looked for in the heart examination at the 6-8 week postnatal check?

Answer 191

• Look for cyanosis, ventricular heave, respiratory distress, tachypnea
• Feel apex beat
• Listen or murmurs

Question 192

What is developmental dysplasia of hip (DDH)?

Answer 192

Ball and socket joint of hip doesn’t form properly - too shallow so femoral head is loose and can dislocate

Question 193

What are the tests for developmental dysplasia of hip (DDH)?

Answer 193

• Barlows test - flex and adduct hip then push hip posteriorly, positive test causes femoral head to slip out of the acetabulum
• Ortolanis test - gently abduct hip, puts dislocated hip back in place

Question 194

What are the normal vital signs of a healthy baby?

Answer 194

• Respiratory rate - 30-60 breaths per minute
• Heart rate - 100-160 beats per minute
• Temperature - 37 degrees celsius

Question 195

What immunisations should be given in the first year of life?

Answer 195

• 8 weeks - 6-in-1 vaccine (1st dose), rotavirus vaccine (1st dose), MenB vaccine (1st dose)
• 12 weeks - 6-in-1 vaccine (2nd dose), pneumococcal (PCV) vaccine, rotavirus vaccine (2nd dose)
• 16 weeks - 6-in-1 vaccine (3rd dose), MenB vaccine (2nd dose)
• 1 year - Hip/MenC vaccine (1st dose), MMR (1st dose), PCV vaccine (2nd dose), MenB (3rd dose)

Question 196

What are the main aims of antenatal care? (6 aims)

Answer 196

• Monitor progress of pregnancy to optimise maternal and foetal health
• Develop a partnership between the other and health professionals
• Exchange information that promotes choice - about lifestyle, location of birth, etc.
• Recognise deviations from the norm and refer appropriately
• Increase understanding of public health issues
• Provide opportunities to prepare for birth and parenthood

Question 197

Which key documents influence antenatal care provisions?

Answer 197

• MBRRACE-UK (mothers and babies - reducing risk through audits and confidential enquiries across the UK)
• NICE antenatal care guideline (2008, modified 2014)
• Evidence based practice
• Local policy/guidelines for practice
• Midwifery 2020
• National maternity review ‘Better births’

Question 198

What were the key themes of the national maternity review ‘Better births’? (7 themes)

Answer 198

• Personalised care
• Continuity of care
• Safer care
• Better postnatal and perinatal mental health care
• Multi-professional working
• Working across boundaries
• A fairer payment system

Question 199

What tests are done at antenatal visits? (3 main tests)

Answer 199

• Physical examination - weight, BP, urinalysis
• Blood tests - FBC, antibodies, ABO and Rh, HIV
• Psychosocial and emotional support - general wellbeing, work, financial, anxiety

Question 200

What are some of the risk factors for adverse outcomes to pregnancy?

Answer 200

• Chronic or acute disease - may be complicated with pregnancy
• Proteinuria - could indicate renal pathology
• Significant increase BP readings - pre-eclampsia, may lead to eclampsia (fits and convulsions)
• Significant oedema - hypertensive disorder?
• Uterus large or small for gestational age - lots of conditions affect these
• Malpresentation - cephalic or breach
• Infection - increases risk of miscarriage/stillbirth
• Social or psychological factors - mental health problems can lead to antenatal depression/postnatal depression

Question 201

What are the different forms of pregnancy loss? (4 types)

Answer 201

• Spontaneous miscarriage - loss of pregnancy before 24 completed weeks of pregnancy
• Ectopic pregnancy - fertilised ovum implants outside uterus (embryo grows in Fallopian tube or even abdomen)
• Termination of pregnancy
• Stillbirth - born after 24 weeks and does not show any sign of life

Question 202

What is the MBRRACE-UK report (2014)?

Answer 202

• Mother and Babies Reducing Risk through Audits and Confidential Enquiries across the UK
• Looked at standards of care and mortality and morbidity rates
• 2/3 of mothers died from medical and mental health problems, 1.3 from direct causes
• 3/4 of women who died had known mental health problems before they died

Question 203

What are common causes of death in the postnatal period? (4 causes)

Answer 203

• Infection
• Haemorrhage
• Thrombosis
• Hypertensive disorders (eclampsia)

Question 204

What physical health and wellbeing issues might a woman experience in the postnatal period? (9 examples)

Answer 204

• Perineal care - infection, inadequate repair, wound breakdown/non-healing
• Urinary retention
• Dyspareunia - difficult or painful sex
• Headache
• Fatigue
• Backache
• Constipation
• Haemorrhoids
• Breast and nipples - redness, painful, cracked, mastitis

Question 205

What mental health problems may be experienced in the postnatal period?

Answer 205

• 50-80% ‘The blues’ - very weepy over small things, time-limited, recovers very quickly, if it continues then begins o worry about postnatal depression
• 10-15% Postnatal depression - tiredness, worthlessness, low mood
• 0.2% Puerperal psychosis - severe episodes of mental illness that begins suddenly, mania, depression, confusion, hallucinations, delusions

Question 206

What are the risks associated with Caesarean section? (3 main risks)

Answer 206

• General anaesthesia, danger of Mendelsohns’ syndrome (aspiration pneumonia), paralytic ileus
• Surgical techniques, quite radical abdominal surgery, risk to other internal organs from surgical trauma
• Childbearing risks for further births

Question 207

What is the medical model of birth?

Answer 207

• Birth seen as a dangerous journey, only normal in retrospect, therefore assume the worst
• Low threshold for intervention (to fix defective bodies)

Question 208

What is the social model of birth?

Answer 208

Birth is seen as a normal physiological process which women are uniquely designed to achieve.

Question 209

What are some of the cultural issues during pregnancy?

Answer 209

• Unintended pregnancy - delay in seeking prenatal care and having a premature baby, higher levels of stress and depression
• Pregnancy may or may not fit with the mother’s plans
• Social disapproval for pregnancy out of wedlock and teenagers

Question 210

What are the benefits of institutionalised childbirth? (5 points)

Answer 210

• Standardisation of care
• Access to good facilities to support childbirth
• Availability of populations of childbearing women and infants for the purposes of midwifery and obstetric training
• Faster access to emergency care
• Access of effective obstetric analgesia

Question 211

What are the risks of institutionalised childbirth? (5 points)

Answer 211

• Medicalisation
• Depersonalisation of birth
• Lack of privacy
• Inflexibility of labour and birth practices
• Limitation of resources

Question 212

What is the role of doctors in welfare?

Answer 212

• You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients
• identifying signs of abuse or neglect early and taking action quickly are important in protecting children and young people
• Know what to do if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect
• Act on any concerns about a child or young person who may be at risk of, or suffering, abuse or neglect

Question 213

What are the indicators of a successful breastfeed?

Answer 213

• Baby - audible and visible swallowing, sustained rhythmic suck, relaxed arms and head, moist mouth, regular soaked nappies
• Mother - breast softening, no compression of nipples at end of feed, relaxed

Question 214

What problems may occur with breastfeeding?

Answer 214

• Nipple pain
• Engorgement
• Mastitis
• Inverted nipple
• Ankyloglossia (tongue ties)
• Sleepy baby

Question 215

What is ‘quality’ in relation to health care?

Answer 215

The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Question 216

Why is there a heavy emphasis on quality management in healthcare?

Answer 216

Quality management produces improved quality, reduced costs, increased productivity and an increased market share

Question 217

Why is consumer protection necessary? (3 medical practice deficiencies)

Answer 217

• Medicine has a weak evidence base
• Large variations in clinical practice - doctors do give different treatments to patients with similar needs and personal characteristics
• Failure to measure success outcomes in healthcare

Question 218

What data are available to improve patient safety? (3 sources)

Answer 218

• Hospital episode statistics (HES) - details referring GP, procedures given, duration of stay and discharge/death, lack of basic national data in primary care
• Patient reported outcome measurements (PROMs) - before procedure and after procedure quality of life measurement slowly developing
• Reference cost data - cost data are poor

Question 219

What is the summary hospital level mortality indicator (SHMI)?

Answer 219

The ratio between the actual number of patients who die within 30 days of discharge compared with the number that would be expected to die on the basis of average

Question 220

What are the key consumer protection agencies? (3 main ones)

Answer 220

• Care Quality Commission (CQC) - regulates ‘quality’ and financial performance of all health and social care providers, public and private, provides regulatory framework, license all providers of health and social care
• NHS Improvement (formerly ‘Monitor’) - ensures financial obligations are met in terms of balancing income and expenditure
• National Institute for Health and Clinical Excellence (NICE) - set standards for treatment

Question 221

Who enforces the NICE guidelines?

Answer 221

• Royal colleges
• GMC
• Professional audit

Question 222

How can consumer protection be improved?

Answer 222

• Appraisal by peers
• Revalidation by the GMC
• Medical audit as a compulsory part of routine practice and annual job planning
• GP and consultant contracts - increasing transparency in comparative performance in relation to activity, costs, and patient reported outcomes
• Transparency and accountability

Question 223

What is clinical governance?

Answer 223

A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish

Question 224

What are the types of neglect? (4 types)

Answer 224

• Physical neglect
• Educational neglect
• Emotional neglect
• Medical neglect

Question 225

What are the signs of neglect? (7 examples)

Answer 225

• Malnutrition, begging, stealing or hoarding food
• Poor hygiene, matted hair, dirty skin, body odour
• Unattended physical or medical problems
• Frequent lateness or absence from school
• Inappropriate clothing, especially inadequate clothing in winter
• Frequent illness, infections or sores
• Being left unsupervised for long periods

Question 226

What are the 4 types of child abuse?

Answer 226

• Physical abuse - deliberate aggressive actions on the child that inflict pain
• Neglect - failing to provide a child’s needs
• Psychological abuse - behaviours towards children that cause mental anguish or deficits
• Sexual abuse - when someone touches a child in a sexual way or commits a sexual act with him or her

Question 227

Who are the people involved in reproductive ethic debates? (3 main parties)

Answer 227

• Parents - procreative autonomy, parents wishes regarding reproductive choice should be respected, state interference should be minimal
• Future or existing child - parents wishes should not be respected if not in interests of the future or existing child
• Third parties, including the state - use of resources, health care providers objections of cosncience

Question 228

What was the main outcome of the human fertilisation and embryology act (1990)?

Answer 228

A woman shall not be provided with fertility treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father)’

Question 229

What were some of the criticisms of the HUMAN FERTILISATION + EMBRYOLOGY ACT (1990) (3 criticisms)

Answer 229

• welfare criterion not defined
• Unfair as Fertile couples don’t have to meet this criterion
• Predicting the welfare of future children is very difficult
• Research suggests that a father isn’t always required for a child to flourish

Question 230

What was the main outcome of the human fertilisation and embryology act (2008)?

Answer 230

Continues to talk about a duty to take account the welfare of the child in providing fertility treatment (hence, welfare criterion remains) but replaces reference to ‘the need for a father’ with ‘the need for supportive parents’, thus valuing role of all parents

Question 231

What is the pro-life argument?

Answer 231

• Abortion ends the life of a foetus.
• Human foetus has the moral status of a person
• It’s wrong to end the life of a person or something with moral status
• Therefore, abortion/termination of pregnancy is morally wrong

Question 232

What is procreative autonomy?

Answer 232

• To have control over one’s reproductive capabilities
• The freedom to choose whether or not to have children

Question 233

What did the abortion act (1967, amended 1990) state?

Answer 233

A person shall not be guilty of an offence under the law relating to abortion when pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- Pregnancy has not exceeded 24 weeks
- Termination is necessary to prevent injury to physical or mental health
- Continuing pregnancy would involve risk to the life of the pregnant woman
- Risk that if the child was born it would suffer from physical or mental abnormalities

Question 234

What are the arguments for assisted reproduction? (4 arguments)

Answer 234

• Procreative autonomy
• Helps get around fertility problems
• More successful than other forms of assisted reproductive technology
• Can help single women and same-sex couples have a child

Question 235

What are the arguments against assisted reproduction? (7 arguments)

Answer 235

• Involves destruction of embryos
• Higher risk of multiple pregnancy with associated risks of mortality and morbidity
• Is ‘unnatural’
• Encourages the mentality which views people as things which can be bought or sold as wanted
• IVF babies are more at risk of birth defects than naturally conceived babies
• Psychological and physical health risk on parents
• ART can be expensive

Question 236

What is pre-implantation genetic diagnosis and what are the associated ethical issues?

Answer 236

• Genetic profiling of embryos prior to implantation (as a form of embryo profiling), and sometimes even oocytes prior to fertilisation
• Can be sued for avoiding genetic diseases
• Issues - sex selection, saviour siblings - ‘Designer babies’

Question 237

What provisions, if any, should be made for doctors who conscientiously object - what are the 3 views?

Answer 237

• Objections should always be respected - the autonomy of the medical provider is paramount, no-one should be made to do something that goes against their strongly held personal beliefs
• Objections should never be respected - women’s interests should always take priority, sometimes argued that if doctors don’t like this then shouldn’t have chosen medicine as a profession
• Objects can sometimes be respected (the GMC’s position) - it might be possible for women’s interests to be met while at the same time not requiring doctors to do something that would cause them a great deal of distress, e.g. perhaps can refer patients to abortion services or provide patients with information.

Question 238

Which act says a 16 year old has full capacity?

Answer 238

The Family Law Reform Act of 1969

Question 239

What is Gillick competency?

Answer 239

Child (under 16) can consent to medical treatment if deemed competent by medical professional, without need for parental permission or knowledge

Question 240

What are Fraser guidelines?

Answer 240

Doctor can give contraceptive advice and treatment to a person under 16 if they are mature and intelligent, likely to continue to have sex, and if the treatment is in their best interests.

Question 241

What should you do before conducting an intimate examination? (5 steps)

Answer 241

• Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
• Explain what the examination will involve
• Get consent and record that the patient has given it
• Offer a chaperone
• Give the patient privacy to undress

Question 242

What is the role of the midwife in postnatal care? (7 key points)

Answer 242

• Screening/identification of actual and/or ‘at risk’ patients
• Pregnancy and postnatal period are ‘window of opportunity; to make lifestyle changes - smoking cessation, diet, exercise
• Sign-posting, liaison and referral - mental health services, MDT working
• Health promotion - women and family
• Source of information - bonding, breastfeeding
• Reassurance and support
• Safeguarding - vulnerable adult or child

Question 243

What are the aims from NICE postnatal care up to 9 weeks after birth guidelines (2006, updated 2015)?

Answer 243

• A documented, individualised postnatal care plan for every woman
• Communication, particularly about transfer of care
• Information giving - empower women to take care of their own health and their baby’s health
• Assess the health and wellbeing of the woman and her baby
• Alert women to signs and symptoms of potentially life-threatening conditions
• Encourages breastfeeding - large proportion of postnatal care
• Assess emotional wellbeing
• Parents should be given information regarding assessing baby’s general condition, identifying common health problems and how to contact a healthcare professional or emergency services if needed

Question 244

Who is in the pregnancy MDT? (7 roles)

Answer 244

• Midwives
• GPs
• Obstetrics
• Support workers
• Health visitors
• Maternity care assistants
• Public health practicitioners

Question 245

What is the role of MDT postnatal care and support teams?

Answer 245

Postnatal care should be a continuation of the care the woman received during her pregnancy, labour and birth, and involve planning and regularly reviewing the content and timing of care, for individual women and their babies

Question 246

What are 4 examples of some of the barriers to MDT work?

Answer 246

• Separate documentation
• Poor working relationship
• Lack of awareness and appreciation of the roles and responsibilities of others
• Limited time and resources
• Overlapping of roles and duplication of services
• Poor communication
• Lack of information sharing
• Lack of collaboration
• Lack of trust and confidence in the abilities of other agencies
• Increased workload
• Lack of appropriately trained staff

Question 247

What is the importance of research-informed practice? (4 points)

Answer 247

• Personal experience is biased in various ways
• Research reports findings for more patients than we can hope to see in personal experience
• Research involves the application of scientific method - testing of hypotheses, systematic data collection, analysis-designed to minimise bias
• Recommendations have been assessed for their clinical and cost effectiveness for the NHS

Question 248

What is the implementation gap?

Answer 248

Gap between scientific understanding and patient care.

Question 249

What are the barriers to implementation of research-informed practice? (4 barriers)

Answer 249

• Characteristics of the recommendations - easy to follow, compatible with existing norms, need for new skills, complexity of recommendations
• Characteristics of the adopters - knowledge, attitudes, skills and abilities
• Characteristics of the organisation - limitations and constraints, organisational culture
• Characteristics of the environment - social influence

Question 250

What is quality improvement (QI)?

Answer 250

Facilitate the uptake and continuing use of evidence-based policy and practice, focusing on recurrent problems within system of care to improve:
- Performance
- Professional development
- Service-user outcomes

Question 251

What does quality improvement involve? (5 aspects)

Answer 251

• Engage participants across organisational levels
• Foster environment where improvement and innovation are viewed as normal
• Empowering staff to strive for change
• Provide knowledge and methods to implement change
• Remove barriers to change

Question 252

Give some examples of quality improvement initiatives

Answer 252

• Revision of professional roles
• Introduction of MDTs
• Change in skill mix, or in the setting of service
• Facilitate audit and benchmarking cycles to identify variations in practice and outcomes that may be targets for QI efforts
• Network recognition for high quality practice
• Promote inter-institutional communication and collaboration (and inter-institutional competition)

Question 253

What makes a quality improvement initiative effective? (3 aspects)

Answer 253

• Passive dissemination of information, such as distribution of educational materials or didactic lectures, is generally ineffective in driving change
• Multifaceted intervention that act of different levels of barriers to change are more likely to achieve improvements in policy and practice
• Key - tailors to the key barriers, no just ‘the usual approach’

Question 254

What is quality and outcomes framework (QOF)?

Answer 254

• Annual reward and incentive programme detailing GP practice achievement results
• Enables commissioners to reward excellence across key domains
• Aims to improve standards of care by assessing and benchmarking the quality of care patients receive - compares delivery and quality of care against previous years

Question 255

Does quality and outcomes framework work?

Answer 255

• Improvements associated with financial incentives seem to be achieved at the expense of small detrimental effects on aspects of care that were not incentivised
• Following the removal of incentives, level of performance across a range of clinical activities generally remain stable

Question 256

What was the aims of national commission for quality and innovation (CQUINs) 2014-15?

Answer 256

• Friends and family test - incentivise high performing providers
• Improvement against the NHS safety thermometer, particularly pressure ulcers
• Improving dementia and delirium care
• Improving diagnosis in mental health

Question 257

What is the incidence of falls in the elderly?

Answer 257

• 35% of 65-79 year olds
• 45% of 80-89 year olds
• 55% of 90+ year olds

Question 258

What are the possible consequences of falls?

Answer 258

• Osteoporotic fractures
• Head injuries
• Contusions, lacerations
• Psychological problem - fear of falling, social isolation, depression
• Increase in dependence and disability
• Impact on carers - time and anxiety
• Institutionalism

Question 259

What are the risk factors for falls?

Answer 259

• Muscle weakness
• History of falls
• Gait deficit
• Balance deficit
• Visual deficit
• Arthritis
• Impaired activities of daily living (AoL)
• Cognitive impairment
• Age (>80 years)
• Medical conditions - PD, stroke, hypotension, depression, epilepsy, dementia, arthritis, peripheral neuropathy, dizziness and vertigo

Question 260

What doesn’t help reduce falls?

Answer 260

• Brisk walking
• Residential care setting - causes an increase
• High intensity strength training - increases injury and strain
• Educational and behavioural preventions alone - need further methods

Question 261

What is QALY?

Answer 261

• Quality adjusted life year
• 1 QALY = 1 year in perfect health
• e.g. if an illness reduces quality of life by 20% (0.2) and this affects 10 people then 2 QALY are lost

Question 262

What is the cost of falls for the NHS each year?

Answer 262

£1.3 billion

Question 263

What is the cost of hip fractures for the NHS each year?

Answer 263

• £12,000 per patient
• Around £720 million per year

Question 264

What is a common fracture in elderly people?

Answer 264

Fracture of the neck of femur

Question 265

What are the two types of fracture of the neck of femur?

Answer 265

• Extracapsular - the bone outside the joint capsule breaks; fixed with sliding hip screw, intramedullary nail
• Intracapsular - the bone within the joint capsule breaks; fixed by internal fixation (screws, nails, plates and rods)

Question 266

What is avascular necrosis?

Answer 266

• Death of bone tissue due to lack of blood supply
• Can lead to tiny breaks in the bone and the bone’s eventual collapse

Question 267

What are the risk factors for hip fractures? (10 examples)

Answer 267

• Low bone mineral density (BMD) is associated with increased fracture risk
• Age - every 5 year increase doubles the risk
• Female gender
• Low body weight (correlates with bone density)
• Family history of hip fracture
• Prior history of hip fracture
• Smoking
• Ethnicity - people of Afro-caribbean descent have very low fracture risk
• Corticosteroid use
• Medications e.g. psychotropic drugs

Question 268

How can hip fractures be prevented?

Answer 268

• Fall prevention
• Bone protection - medication (bisphosphonates, calcium & vitamin D), hip protection

Question 269

What is primary prevention?

Answer 269

Avoidance of disease before any signs or symptoms develop

Question 270

What is secondary prevention?

Answer 270

Avoidance of progression or later problems, signs or symptoms present

Question 271

What would be primary and secondary prevention be in relation to stroke?

Answer 271

• Primary - no history of stroke or TIA
• Secondary - after either of these have occurred

Question 272

What is the prevention paradox?

Answer 272

• The majority of people who suffer a stroke are not at high risk of stroke (e.g. 75% have ‘normal’ blood pressure)
• But if the whole population changes their health behaviour via public health mechanisms, this would lead to a much greater effect

Question 273

What are the effects of targeting population for prevention?

Answer 273

• Large potential benefit to community
• Low potential benefit to individual
• May be low perceived benefit to individual

Question 274

What are the effects of targeting high risk groups for prevention?

Answer 274

• Larger potential benefit to individual
• Smaller effect in population rate of stroke
• Many of the conditions you treat are asymptomatic
• Many of the treatments have side effects

Question 275

Which group of people are at the highest risk from stroke?

Answer 275

• people who have already had one - secondary prevention reduces risk in these people
• 1/5 people with stroke have another after 3 months

Question 276

What medication is used for secondary prevention of strokes?

Answer 276

• Ischaemic - clopidogrel, statins, anti-hypertensives, anticoagulant if AF
• Haemorrhagic - anti-hypertensives

Question 277

What percentage of people who have strokes are under 50 years old?

Answer 277

<20%

Question 278

What is the incidence in strokes in men and women?

Answer 278

• Men are at a 25% higher risk of having stroke and at a younger age compared to women
• However, as women tend to live longer there are more total incidences of stroke in women

Question 279

What are the non-modifiable risk factors for stroke?

Answer 279

• Age
• Gender
• Race - South Asian descent with western lifestyle
• Family history - rare congenital (in young people - CADASIL)

Question 280

What are the modifiable risk factors for strokes? (6 factors)

Answer 280

• High blood pressure - biggest risk factor
• Diabetes
• Atrial fibrillation
• Smoking
• Hyperlipidaemia
• Obesity

Question 281

What did the PROGRESS trial show?

Answer 281

Reducing blood pressure after stroke reduces risk of stroke recurrence.

Question 282

What are the barriers for initiating medical therapies for conditions with no obvious symptoms? (6 barriers)

Answer 282

• Misinformed
• Not caring
• Side effects of tablets
• Forgetfulness
• Depression
• Cognitive impairment

Question 283

What is a confounding factor?

Answer 283

• Distortion of the relationship between an exposure and outcome due to shared relationship with something else
• Confounders can either increase associated associated between exposure and outcome, or decrease association between exposure and outcome

Question 284

How can we limit confounding factors and what are the effects? (4 strategies)

Answer 284

• Restriction - limit the participants of your study who have possible confounders; means that you have less data and difficult with multiple confounders
• Matching - you create a comparison group that is matched on the possible confounder, make case and control group as similar as possible on the confounder and then ask about exposure status; use for strong confounders like age and sex
• Stratification - analyse exposure-outcome association in different subgroups of the confounder, recombine data and use a weighted average of the strata; limitations - to take into account all confounders would require lots of strata and you may run out of data to fill all possible options n your strata
• Multiple variable regression - you can adjust for the effects of multiple confounders, try and produce a linear model between the outcome and the different exposures; allows for adjustment of estimates for confounding

Question 285

What is standardisation?

Answer 285

Way to limit confounding, often used to control for differences in age groups when comparing rates of disease in two populations with different age structures

Question 286

What is standardised mortality ratio (SMR)?

Answer 286

Ratio between the observed number of deaths in a study population to the number of expected deaths

SMR = observed number of deaths / expected number of deaths

Question 287

What is direct standardisation?

Answer 287

Required we know the age-specific rates of mortality in all populations under study

Question 288

What is indirect standardisation?

Answer 288

Only requires that we know the total number of deaths and the age structure of the study population.

Question 289

Why do we have waiting lists?

Answer 289

• There is a limitless demand for health, people can always ‘be more healthy’ which created high demand
• limited resources - supply of money, staff, etc. is finite

Question 290

Why are waiting times important to patients? (5 examples)

Answer 290

• The patient’s condition may deteriorate while waiting and in some cases the effectiveness of the proposed treatment may be reduced
• Experience of waiting can be extremely difficult distressing in itself
• Patient’s family life may be adversely affected by waiting
• Patient’s employment circumstances may be adversely affected by waiting
• Excessive waiting times may be symptoms of inefficiencies in the healthcare system and should be addressed as part of good management

Question 291

How can you measure waiting times? (3 methods)

Answer 291

• Average waiting times (mean or median)
• Proportion who waited longer than ‘x number of days’
• Average wait of people currently on the list

Question 292

What are the theories of NHS waiting lists?

Answer 292

• The backlog - implies a need for occasional emergency injection of funds
• Demand management - waiting acts as a ‘price’ to deter frivolous use
• Allows NHS resources to be fully employed - don’t want lots of spare capacity as this is a waste
• Waiting lists are caused by underfunding and inefficiency

Question 293

How can the NHS reduce waiting times? (4 methods)

Answer 293

• Manage demand - ensuring each referral represents the most appropriate decision for the care of the individual patient
• Manage the queue - ensuring waiting lists are well managed and patients are called for treatment in appropriate order
• Manage capacity - providing efficient and effective services that meet the level of demand from appropriate referrals
• Provide leadership - ensuring that all parts of the local NHS work together to achieve waiting time improvements in the best interests of patients

Question 294

What was the 2002-2008 policy ‘targets and terror’?

Answer 294

• Performance management of Trusts and PCTs based on achievement of target waiting times.
• Hospitals receive an overall performance score and managers could lose their jobs if targets missed.

Question 295

What are the pros of ‘targets and terror’ policy?

Answer 295

• No inpatients waiting longer than 3 months
• Outpatients reduced, significant increased expenditure alongside this, however funding has now remained constant meaning NHS is struggling despite increased demand

Question 296

What were the cons of ‘targets and terror’ policy?

Answer 296

• Sacrifice of professional autonomy - managers pressuring doctors, may be forced to treat les urgent due to waiting times
• unmeasured performance sufferers - things that don’t have a target may suffer
• Adverse behavioural responses - e.g. emergency patients waiting in ambulances not emergency rooms, not classed as being in A&E until they are through the doors so essentially cheating
• Data manipulation and fraud

Question 297

What is possible criteria for priority on a waiting list? (6 examples)

Answer 297

• Clinical urgency
• Clinical severity
• Potential health gain
• Productivity and economic loss
• Equity waiting e.g. poverty
• Length of time waiting

Question 298

What are the social consequences of deafness?

Answer 298

• Social impact - difficult to have conversations, isolation, intimacy issues, problems at work
• Psychological impact - anger, low confidence, frustration, depression, embarrassment
• Practical issues - doorbells, phones, theatre and cinema, TV, alarms

Question 299

How can a stroke affect communication?

Answer 299

• Aphasia (and sometimes dysphasia) - difficulty in the generation of speech and sometimes also in its comprehension
• Dysarthria - difficult or unclear articulation of speech that is otherwise linguistically normal (due to weakness of muscles used to speak)
• Dyspraxia - affects movement and coordination, cannot move muscles int he correct order and sequence to make the sounds needed for clear speech

Question 300

What are the social consequences of speech and communication difficulties?

Answer 300

• Not being able to express yourself clearly can be very isolating
• Depression
• Frustrating
• May not be able to participate in activities they used to enjoy
• Tiring - communicating may require a lot of effort

Question 301

What areas can medico-legal implications occur in a person with epilepsy?

Answer 301

• Determination of fitness to drive and other similarly dangerous activities
• Determination of intent for alleged criminal actions

Question 302

What are the rules for whether people can drive with epilepsy?

Answer 302

• Group 1 which applies to cars, motorbikes, and most other small vehicles - need to be seizure free for 12 months
• Group 2 which applies to bigger vehicles such as lorries, heavy goods vehicles and other specialised types of vehicle - unlikely to qualify for group 2 licence, need to be seizure free for 10 years and have not taken epilepsy medicines for 10 years

NEW RULES relating to whether people can drive if:
- They have only had seizures while they sleep
- They have only had seizures that do not affect their consciousness
- Their doctor changed their dosage or medication, but they have now gone back to the original dosage or medication

Question 303

What are CAMs?

Answer 303

• Complementary - non-mainstream practice is used together with conventional medicine
• Alternative - non-mainstream practice is used instead of conventional medicine

Question 304

What are the 5 big CAMs?

Answer 304

• Acupuncture - fine needles are inserted at certain sites in the body for therapeutic or preventative purposes
• Chiropractic - spinal manipulation aims to treat ‘vertebral subluxations’ which are claimed to put pressure on nerves
• Herbal medicine - medicines with active ingredients made from plant parts
• Homeopathy - based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself
• Osteopathy - moving, stretching and massaging a person’s muscles and joints

Question 305

What is the underlying principle with CAMs?

Answer 305

• Self-healing is triggered
• Longer-term effects may be due to physiological (re-)learning and behavioural/lifestyle changes integral to treatments
• Each therapy has its own mechanism(s) - mostly poorly understood

Question 306

What percentage of CAMs are covered by the NHS?

Answer 306

10%

Question 307

What are the barrier to CAMs on the NHS? (5 main barriers)

Answer 307

• Regulatory issues
• Financial concerns in NHS
• Tribalism - different medical specialties ‘hold on’ to their patch
• Inertia - resistance to change
• Mixed evidence of effectiveness - not all are properly evidence-based

Question 308

Why should CAMs be provided by the NHS? (5 arguments)

Answer 308

• Patient choice
• Preventative healthcare agenda
• Commissioning changes
• Personal budgets
• Growing evidence base

Question 309

Which complementary therapy is most used for MSK problems?

Answer 309

Osteopathy

Question 310

What is osteopathy used mainly to treat? (5 problems)

Answer 310

• Back pain
• Repetitive strain injury
• Changes to posture in pregnancy
• Postural problems caused by driving or work strain
• The pain of arthritis and sports injuries

Question 311

What do chiropractors mainly treat?

Answer 311

• Back, neck and shoulder problems
• Joint, posture and muscle problems
• Leg pain and sciatica
• Sports injuries

Question 312

What is acupuncture used to treat?

Answer 312

• MSK patients
• Fertility/pregnancy - has become much more popular
• Neurological pain
• Depression
• Eczema
• Chronic pain
• Irritable bowel

Question 313

Why are people using acupuncture?

Answer 313

Effectiveness gap - a clinical area where available treatments are not fully effective or satisfactory for various reasons including lack of efficacy, adverse effects and acceptability to patients

Question 314

What is the evidence base for acupuncture?

Answer 314

• Acupuncture correlated with physiological parameters i.e. with decreases in brain flow
• Acupuncture can be seen as having an overall effect vs usual care
• More effective than no treatment or sham treatment for lower back pain (indicate it is more than a placebo) but there are no differences in effectiveness compared with other conventional therapies
• Acupuncture, osteopath, chiropractic shown to be effective when compared to usual care
• As is the case with biomedicine, more and better research is needed

Question 315

What are the criticisms of acupuncture?

Answer 315

• Is the effect too small and not clinically relevant?
• NSAIDs are commonly given for chronic back pain - NSAID vs placebo and acupuncture vs placebo have similar effect for pain reduction

Question 316

What are the 5 categories for significant impaired decision making ability?

Answer 316

• Lack of insight - person suffers from some disability but seem unaware of the existence of their disability
• Cognitive impairment - e.g. dementia
• Presence of psychosis
• Severe depressive symptoms
• Learning disability

Question 317

Why is it important to support patients decision making? (5 reasons)

Answer 317

• Patients generally happier if they can make decisions
• Enables patients to have self-determination, autonomy
• Likely to facilitate other positive goods - good doctor-patient relationship
• A professional requirement (GMC)
• A legal requirement - Mental capacity act (2005)

Question 318

How might doctors assist patients in making decisions? (4 methods)

Answer 318

• Using a different form of communication
• Providing information in a more accessible form
• Treating a medical condition affecting the person’s capacity
• Having a structured programme to improve a person’s capacity

Question 319

Which act are capacity determinants governed by?

Answer 319

Mental capacity act (2005)

Question 320

According to the mental capacity act, when does a person lack capacity?

Answer 320

A person lacks capacity if they are unable to:
- Understand information that may be relevant to the decision, including the consequence
- Retain information, even for a short time
- Use or weigh information to make decisions
- Communicate decision

Question 321

What are the 5 key principles of the mental capacity act?

Answer 321

• Presumption of capacity - a person must be assumed to have capacity until proven otherwise; assumption can be over-ridden if shown to lack capacity for that decision at that time
• Right to be supported to make their own decisions - use different forms of communication, provide information in different formats, treat a condition that is impacting capacity thus restoring capacity
• Right to make eccentric or unwise decisions - a person is not to be treated as unable to make a decision merely because it is an unwise one
• Best interests - a decision made under the MCA for someone lacking capacity must be done in their best interests
• Least restrictive intervention - before the decision is made you should explore other less restrictive options

Question 322

How many people in the UK have dementia?

Answer 322

Approximately 850,000 people

Question 323

How might dementia first present?

Answer 323

• Patient noticing changes - forgetfulness, difficulty with names and finding the right word, embarrassment in social situations
• Family or friends noticing changes - repetitive, forgets social arrangements, skills deteriorating, withdrawing
• Delirium - acute confusion with fluctuating level of consciousness, agitation, hallucinations, etc.
• Social crisis - e.g. death of a spouse reveals cognitive dysfunction and impairment

Question 324

What is the impact of diagnosis of dementia on a patient?

Answer 324

• Denial (with or without insight) - patient attributes all problems to old age, often accompanied by anger at the suggestion that there is anything wrong
• Grief reaction - similar reaction to receiving diagnosis of any serious illness
• Acceptance/positive coping strategies - need to reconsider the future

Question 325

What determines the response of the patient to the diagnosis of dementia?

Answer 325

• Insight and stage of illness - ability to remember and process information
• Type fo dementia
• Previous personality, relationship, and support

Question 326

What is the impact of diagnosis on the carers?

Answer 326

• Confirmation of something they have long suspected
• Fear
• Anger
• Grief

Question 327

What determines the response of the carer to the diagnosis?

Answer 327

• understanding of illness
• Patient’s reaction
• Nature of the relationship with the patient and what else is happening

Question 328

What are the benefits of diagnosis?

Answer 328

• Know what it is that you are dealing with
• Access to treatments
• Access to support services
• Information/education
• Planning for the future - financial affairs, etc.
• Assess and manage risks - e.g. driving, etc.

Question 329

Describe the effect of dementia on the patient, spouse/partner, children and carers

Answer 329

• Patient - loss of self-esteem, may find communication difficult, loss of independence and autonomy, change in social roles and relationships, impact on ADLs
• Partner - relationship becomes skewed, practical, emotional, financial, strained relationship with family/friends
• Child - role reversal, competing demands, conflict between family members, effect on young children, previous relationship
• Carers - stress, physical care, poor sleep, constant vigilance, loss of support, unable to take time off sick

Question 330

How much of the cost of dementia is paid by people with dementia and their families?

Answer 330

2/3 = £17.4 billion

Question 331

What percentage of carers don’t receive enough support?

Answer 331

43%

Question 332

Why are people with dementia at high risk of elder abuse? (3 main reasons)

Answer 332

• More vulnerable
• May struggle to discuss their feelings and experiences or remember what happened to them
• Can be hard to detect abuse

Question 333

What are examples of advanced care planning?

Answer 333

• Advanced statement of wishes - wishes and preferences about treatment/care they would like (NOT legally binding hence can use best interests judgement)
• Advanced decisions/directives - a decision to refuse treatment (LEGALLY BINDING so should always be followed)

Question 334

What are advanced directives?

Answer 334

• Extends patient autonomy to apply in situations where they don’t have capacity as defined under the MCA 2005
• A valid AD that refuses treatment should always be followed
• ADs allow patients refuse treatment but not to demand treatments

Question 335

What are advanced directives valid and applicable?

Answer 335

• Patient is 18+ - note MCA is for 16+ but only 18+ can refuse treatment
• Patient lacks capacity at the time of treatment but had capacity at time of making AD
• Properly informed patient and statement is clear and applicable to current situations
• ADs can be used to refuse life-saving treatments but cannot be used to refuse basic care e.g. food/water

Question 336

What is Ulysses arrangement?

Answer 336

Advanced directive for bipolar disorder

Question 337

What are the pros of advanced directives?

Answer 337

• Respect patient autonomy
• Encourages forward planning
• Patient will be less anxious about unwanted treatment
• May lower healthcare costs as people opt out for less aggressive treatments

Question 338

What are some of the research atrocities in history?

Answer 338

• Nazi medical experiments (Nuremberg trials)
• Willowbrook study - injected vulnerable children with Hep B to develop vaccine
• Tuskegee syphilis study - African-American men given syphilis but not given antibiotics, researchers wanted to see disease progression
• Alder Hey - retaining children organs without consent
• Wakefield - MMR scandal (autism claim)

Question 339

What is the Nuremberg Code (1947)?

Answer 339

The Nuremberg code resulted from the Nuremberg trials. It was an early code for research ethics principles, including:
- Need for voluntary consent
- Avoid all unnecessary physical and mental suffering and injury
- Conducted only by scientifically qualified persons

Question 340

What is the Helsinki declaration (1964)?

Answer 340

Includes requirement that any human research is subject to independent ethical review and oversight by properly convened committee

Question 341

What are some research ethics principles? (6 examples)

Answer 341

• Usefulness - valid, good method, hasn’t been done before, strong justification
• Necessity - does it need to be done this way?
• Risks - risks should be as low as possible, sometimes balance minimal risk with benefits
• Consent - valid (competent, voluntary, informed), deception is sometimes needed e.g. psychological studies
• Confidentiality - respect patients information
• Fairness - who benefits? will it favour particular population group?
• Approval - from research ethics committee

Question 342

What is valid consent?

Answer 342

Voluntary, informed, patient is competent

Question 343

What does voluntary consent mean?

Answer 343

• Not putting pressure on patients or volunteers
• Not offering inappropriate (financial) inducements
• Not threatening/imposing sanctions if they don’t take part

Question 344

What should patients be given to facilitate consent?

Answer 344

• Information sheets
• Presentation of information - no jargon, easy to understand
• Summary of key points
• Opportunity to ask questions
• Time to decide - at least 24 hours

Question 345

What is confidentiality and why it is important?

Answer 345

• Confidentiality is the state of keeping or being kept secret or private
• It is important for patient trust and for ensuring valid results
• All patient information is confidential

Question 346

How can we increase the level of confidentiality?

Answer 346

• Limit access to identifiable information
• Securely store data documents
• Assign security codes to computerised records
• Properly dispose, destroy or delete study data/documents
• Encrypt identifiable data

Question 347

What is an ethics committee?

Answer 347

Body responsible for ensuring that medical experimentation and human research are carried out in an ethical manner in accordance with national and international law.

Question 348

Why do we need ethics approval? (5 reasons)

Answer 348

• To protect participants
• Make sure no harm to researchers
• Researcher will not be covered is a claim regarding the research is made against them
• Many publications will not accept research that was not ethically approved
• Funders will not provide financial support without ethical approval

Question 349

When is ethics approval needed? (3 examples)

Answer 349

• Research involves humans
• Research involves confidential information
• Research involves biological material (embryos, stem cells, etc.)

Question 350

What are some of the types of research ethics committees?

Answer 350

• NHS research ethics committees
• Higher education institution (HEI) research ethics committees
• Gene therapy advisory committee
• Social care research ethics committee
• Ministry of defence research ethics committee

Question 351

What does the human tissue act (2004) state about research?

Answer 351

• Consent for storage and use of tissue for ‘scheduled purposes’ is required for tissues from living or deceased persons
• These purposes include research in connection with disorders, or the functioning of the human body
• However, consent is not required to use tissue obtained from living patients if the tissue is anonymous to the researcher and the project has research ethics approval

Question 352

What percentage of deaths does CHD cause in the UK?

Answer 352

• 29% men
• 28% women

Question 353

Why are the death rates falling from CHD?

Answer 353

• Risk factors improved - fewer smokers, cholesterol better controlled, HTN controlled
• Treatments - medical interventions improved for various cardiac conditions

Question 354

What is the effect of health inequalities on CHD?

Answer 354

Lower social class at higher risk - health behaviours

Question 355

What are the non-modifiable risk factors for CHD?

Answer 355

• Elevated blood cholesterol
• High LDL, low HDL
• High BP
• Diabetes
• Smoking
• Obesity
• Excessive alcohol
• Inactivity
• Excessive stress

Question 356

What is risk?

Answer 356

The probability of an event in a given time period

Question 357

What is the equation for risk ratio?

Answer 357

Risk ratio = risk for exposed / risk for non-exposed

Question 358

What is the equation for risk difference?

Answer 358

Risk difference = Risk for exposed - Risk for non-exposed

Question 359

What is odds ratio?

Answer 359

A ratio of the odds of an event in an exposed group to the odds of the same event in a group that is not exposed

Question 360

What is the equation for odds ratio?

Answer 360

OR = ad/bc

a = disease with exposure (case)
b = no disease with exposure (control)
c = disease with no exposure (case)
d = no disease with no exposure (control)

Question 361

What is population attributable risk?

Answer 361

The risk of disease will increase as the exposure prevalence or relative risk increases

Question 362

What is the leading cause for cancer mortality?

Answer 362

Lung cancer

Question 363

What are the main risk factors associated with lung cancer?

Answer 363

• Smoking
• Radon
• Asbestos
• Environmental tobacco exposure
• Genetics
• Other lung diseases
• Prior radiation in chest area

Question 364

What percentage of lung cancer cases are cause by smoking?

Answer 364

90%

Question 365

What is the second leading cause of lung cancer after smoking?

Answer 365

Radon

Question 366

What are the different types of lung cancer?

Answer 366

• Small cell (13%)
• Non-small cell (87%) - adenocarcinoma (>40%), squamous cell carcinoma (20%), large cell carcinoma (2%)
• Mesothelioma

Question 367

What are the factors associated with recent increases in the prevalence of TB? (4 main factors)

Answer 367

• Urban homelessness
• IV drug use
• Growing neglect of TB control programmes
• AIDS epidemic

Question 368

What time of year does TB incidence peak?

Answer 368

Spring/summer

Question 369

What can be done to address rising rates of TB?

Answer 369

• Put more people on ART
• New vaccine
• Improved drugs
• Diagnose better

Question 370

What is the prevention paradox?

Answer 370

A preventative measure that brings large benefits to the community offers little to each participating individual

Question 371

What are the pros of ‘high risk’ approaches to health promotion?

Answer 371

• Appropriate to individual
• Motivated subject
• Motivated clinician
• Cost-effective resource use
• benefit for risk is high

Question 372

What are the cons of ‘high risk’ approaches to health promotion?

Answer 372

• Screening is difficult
• palliative and temporary
• Limited potential as not many people
• Labelling

Question 373

What are the pros of ‘population’ approaches to health promotion?

Answer 373

Large potential as targeting many people

Question 374

What are the cons of ‘population’ approaches to health promotion?

Answer 374

• Population paradox - small perceived individual benefit
• Poor motivation can cause compliance issues
• Benefit for risk is low

Question 375

How have occupational health risks changed over time?

Answer 375

• Better environmental control an health and safety - e.g. from mid 20th century with coal mining, etc.
• Depends on health of the population and local industry
• Diagnosis of occupational lung disease (e.g. occupational asthma) has improved
• Biological factors - predisposing/protective factors

Question 376

What is occupational asthma?

Answer 376

Like other types of asthma, it is characterised by airway inflammation, reversible airways obstruction, and bronchospasm, but it is caused by something in the workplace environment

Question 377

Give some examples of occupations that are at a higher risk for occupational asthma

Answer 377

• Bakers
• Welders
• Paint sprayers
• Laboratory workers

Question 378

What history would you expect from a patient with occupational asthma?

Answer 378

• Symptoms worse at work and better away from work e.g. weekends and holidays
• Peak flow falls at work and improves away from work

Question 379

Give some occupational causes of COPD

Answer 379

• Coal mining
• Agricultural jobs
• Contraction workers
• Dock workers
• Brick making

Question 380

What is simple coal workers pneumoconiosis?

Answer 380

• After around 10 years of coal mining, small nodules are present
• Shouldn’t cause major impairment in lung function
• Some coal workers have symptoms of chronic bronchitis (cough)

Question 381

What are possible complications with coal workers pneumoconiosis?

Answer 381

• Occurs in coal workers especially fi the coal they work with is heavily contaminated with silicates
• Very serious - scarred, fibrotic tissue distorts the remaining lung (gross obstruction and restriction)

Question 382

What is silicosis?

Answer 382

• Occupational lung disease caused by inhalation of crystalline silica dust, and is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lung
• It is a type of pneumoconiosis

Question 383

What is siderosis?

Answer 383

• Deposition of iron in tissue
• Iron has no effect on lungs - no associated fibrosis or narrowed airways

Question 384

What is acute pneumonitis?

Answer 384

• Acute inhalation of a substance that causes symptoms immediately
• Can be caused by chlorine, ammonia, organic chemicals, metallic compounds
• Form of acute respiratory distress syndrome

Question 385

What is hypersensitive pneumonitis?

Answer 385

• Type 3 hypersensitivity reaction (immune complex deposition)
• It is an inflammation of the alveoli within the lung caused by hypersensitivity to inhaled organic dust

Question 386

What are some causes of hypersensitive pneumonitis?

Answer 386

• Bird fancier’s lung - due to feathers and bird droppings
• Farmer’s lung - due to mouldy hay (moulds and bacteria)
• Metalworking fluids HP - due to mist from metalworking fluids (non-TB mycobacterium)

Question 387

What percentage of lung cancers in men are related to occupation?

Answer 387

10%

Question 388

What is mesothelioma?

Answer 388

• Cancer of the mesothelium almost inevitably caused by occupational exposure asbestos
• Latency period of around 40 years

Question 389

Where are claims submitted for compensation for occupational illness in the UK?

Answer 389

Disability benefits centre of benefits agency (DSS)

Question 390

What does decision analysis assume?

Answer 390

• Decision process is logical and rational
• A rational decision maker will choose the option to maximise utility (the desirability or value attached to a decision outcome)

Question 391

What are the stages in decision analysis? (4-5 stages)

Answer 391

1. Structure the problem as a decision tree - identifying choice, information (what is and is not known) and preferences
2. Assess the probability (chance) of every choice branch
3. Assess (numerically) the utility of nervy outcome
4. Identify the option that maximises unexpected utility
5. (Possibly) Conduct a sensitive analysis to explore effect of varying judgements

Question 392

What do squares and circles mean on decision trees?

Answer 392

• Squares - indicated decision, represents choice between actions
• Circles - indicated chance (probability), represents uncertainty, potential outcomes of each decision

Question 393

How do you calculate expected utility?

Answer 393

Expected utility = utility value x probability

Question 394

What is sensitive analysis?

Answer 394

Sensitive analysis explores what would happen if the probabilities or utility values were slightly different to the ones you are using - calculate effect of uncertainty on decision

Question 395

What are preference sensitive and probability sensitive decisions?

Answer 395

• Preference sensitive - the person might feel strongly about the side effects of the treatment
• Probability sensitive - sensitive to changes int he chance of different outcomes

Question 396

What are the benefits of using decision analysis to make decisions? (5 benefits)

Answer 396

• Makes all assumptions in a decision explicit
• Allows examination of the process of making a decision
• Integrates research evidence into the decision process
• insight gained during process may be more important then the generated numbers
• Can be used for individual decisions, population levels decisions and for cost-effectiveness analysis

Question 397

What are the negatives of using decision analysis to make decisions?

Answer 397

• Probability estimates - required data sets to estimate probability may not exist; subjective probability estimates are subject to bias
• Utility measures - individual may be asked to rate a state of health they have not experienced; different techniques will result in different numbers; subject to presentation framing effects; the approach is reductionist

Question 398

What is the ICF model of disability?

Answer 398

Functioning and disability are multi-dimensional concepts relating to:
- Body functions and structures - physiological functions and anatomical parts of the body, including cardiac and respiratory systems
- Activities
- Participation of people in life
- Environmental factors

Question 399

What is palliative care?

Answer 399

• Active holistic care of patients with advanced progressive illness
• It aims to treat or manage pain and other physical symptoms and will also help with any psychological, social or spiritual needs

Question 400

What are the goals of palliative care? (8 goals)

Answer 400

• Improves quality of life
• Provides relief from pain and other distressing symptoms
• Supports life and regards death as a normal process
• Doesn’t quicken or postpone death
• Combines psychological and spiritual aspects of care
• Offers a support system to help people live as actively as possible until death
• Offers a support system to help the family cope during a person’s illness and in bereavement
• Uses an MDT approach to address the needs of the person who is ill and their families

Question 401

Who is general palliative care given to?

Answer 401

Core aspect of care for all patients and their families with advanced disease by all health professionals

Question 402

Who is specialised palliative care for?

Answer 402

Patients (and carers) with unresolved symptoms and complex psychosocial issues, with complex end-of-life and bereavement issues.

Question 403

Who provides specialised palliative care?

Answer 403

• NHS - community/hospital clinic nurse specialist, some consultants, some inpatient units, macmillan
• Voluntary - hospice services, inpatient beds, independent charities (Marie Curie, Sue Ryder), macmillan

Question 404

What is end of life care?

Answer 404

• Branch of palliative care - caring for people who are nearing the end of life
• ‘End of life care pathway’ - last 48 hours of life

Question 405

What are some of the challenges for the future of palliative care?

Answer 405

• Inequality of service provision and standards
• Funding
• Training, recruitment and retention
• Maintaining a sense of humanity and compassion - due to increasing technologies and treatment options for management of disease

Question 406

What is ‘total pain’?

Answer 406

Recognises pain as being physical, psychological, social and spiritual

Question 407

What are the different types of nurses involved in palliative care? (4 main types)

Answer 407

• District nurse - primary health care team, community based, generic palliative care skills, ‘hands on’ nursing skills
• Practice nurse - primary health care team, practice based, generic palliative care skills, ‘hands on’
• Marie Curie nurse - community based, arranged by district nurse, specialist palliative care skills, ‘hands on’
• Macmillan nurse - community or hospital based, specialist palliative care advice, support, resource

Question 408

What percentage of admission notes document the CPR decisions?

Answer 408

10%

Question 409

What percentage of in-hospital CPR is not appropriate?

Answer 409

40-50%

Question 410

What is DNACPR?

Answer 410

Do Not Attempt CPR - decision made and recorded in advance, applies to those present if a person subsequently suffers sudden cardiac arrest or dies

Question 411

What are Bowlby’s 4 stages of grief?

Answer 411

• Numbness
• Yearning/pining and anger
• Disorganisation and despair
• Reorganisation

Question 412

What are the symptoms of grief?

Answer 412

• Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, numbness
• Somatic sensations - stomach, chest, throat, sensitivity to noise, depersonalisation, breathlessness, muscle weakness, lack of energy, dry mouth
• Concentration impairment, preoccupation with the deceased, hallucinations, disbelief
• Sleep and appetite disturbance, absent-mindedness, social withdrawal, dreams of deceased, avoidance of reminders, searching and calling out, sighing, overactivity, crying

Question 413

What is Warden’s tasks of mourning? (4 tasks)

Answer 413

1. Accepting the reality of the loss e.g. come to terms with the person being ‘gone’
2. Work through the pain of grief
3. Adjust to an environment in which the deceased is missing
4. Emotionally relocate the deceased and move on with life

Question 414

What factors affect the severity of grief? (6 factors)

Answer 414

• Closeness of relationship
• Meaningfulness of relationship
• Nature of relationship prior to death
• Expectedness and manner of death
• Age and developmental stage of griever
• Social support

Question 415

What is spirituality?

Answer 415

Umbrella term that includes religious/faith frameworks, but it also includes the meaning of life, purpose, sense of personhood

Question 416

How can religious beliefs impact on bereavement?

Answer 416

• Belief in an afterlife - the continuing existence of the loved one and possibility of meeting up again
• Continued attachment - prayer as means of continuing connection with the deceased
• Defence against fear of personal death/extinction
• Religious funeral rituals that aid and progress the grief process
• Religious funeral rituals that recruit social support

Question 417

What is pathological grief?

Answer 417

• Extended grief reactions - getting stuck in one of the phases (normally each phase is about 6 months)
• Can be in denial for an extended period of time - exhibit mummification (not changing things in dead persons room for example)
• Major depressive disorders >2 months after loss

Question 418

What is the myth of the neutral therapist?

Answer 418

• Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
• This will come across in their questioning/direction of questioning

Question 419

What are CDSS?

Answer 419

Clinical decision support system - designed to aid clinician decision making

Question 420

What are the different types of CDSS?

Answer 420

• Computerised
• Paper based
• Reminder systems
• Developed to aid with particular decisions

Question 421

What are some examples of CDSS? (4 examples)

Answer 421

• Reminder systems - screening, vaccination, testing, medication use
• Decision systems (diagnosis and treatment) - model individual patient data against epidemiological data
• Prescribing - advice on drug and dosage, highlights potential drug interaction
• Condition management - Assists monitoring patients

Question 422

What are the effects of computer support on prescribing? (6 main effects)

Answer 422

• Reduced time to achieve therapeutic stabilisation
• Reduced risk of toxic drug level
• Reduced length of hospital stay
• Increased size of initial dose
• Increased serum drug concentration
• No change in adverse effects of drug

Question 423

Do CDSS work?

Answer 423

• Can improve practitioner performance in diagnosis, disease management, prescribing/drug dosing, rates of vaccination, screening, etc.
• Evidence for effects on patient outcomes not so robust

Question 424

What are patient decision aids?

Answer 424

• Help patient understand probable outcomes of options
• Help patient consider the personal value they place on benefits vs harm
• Support patient in decision making
• Include additional information - on disease, costs, probability of outcomes, peoples opinions

Question 425

What is the key issue with patient decisions aids?

Answer 425

No consensus on what information should be included in a patient decision aid

Question 426

What improves practice when using decision support? (4 examples)

Answer 426

• Providing decisions support as part of the clinician workflow
• Providing recommendations for management (not just patient assessments)
• Providing decision support when and where decision making was happening
• Computer-based decision support

Question 427

What are potential barriers to using CDSS? (4 examples)

Answer 427

• Earlier negative experience of IT
• Potential harm to doctor-patient relationship
• Obscured responsibilities (loss of autonomy or reasoning)
• Reminders increase workload

Question 428

What are potential facilitators of CDSS?

Answer 428

• Self-control of CDSS
• If clinical can notice help in practice

Question 429

What is food poisoning?

Answer 429

Diarrhoea and vomiting with or without pain

Question 430

What are the major causes of food poisoning?

Answer 430

• Not cooking food thoroughly (particularly meat)
• Not correctly storing food that needs to be chilled
• Keeping cooked food unrefrigerated for a long period
• Eating food that has been touched by someone who is ill or has been in contact with someone with diarrhoea or vomiting
• Cross-contamination e.g. preparing raw meat on a chopping board then preparing salad on the same board

Question 431

What are some microbial infections that cause food poisoning?

Answer 431

• Bacterial - salmonella, campylobacter, shigella, C. difficile
• Viral - norovirus, rotavirus
• Fungal - aspergillus
• Protozoal - cryptosporidia, giardia

Question 432

What are some chemicals that cause food poisoning?

Answer 432

• Heavy metals
• Pesticides
• Herbicides

Question 433

What is the most common cause of food poisoning?

Answer 433

Campylobacter

Question 434

Describe the clinical picture of salmonella infection (transmission, incubation, symptoms)

Answer 434

• Transmission - ingestion of contaminated food, faecal contaminations, person-person, infected animals
• Can cause enteric fever or enterocolitis
• Incubation period is 12-72 hours
• Symptoms - vomiting, diarrhoea, fever, headache, chills

Question 435

Describe the clinical picture of staphylococcus aureus infection (transmission, incubation, symptoms)

Answer 435

• transmission - contaminated food by skin/nasal flora
• Produces enterotoxins
• Incubation - 24 hours
• Symptoms - rapid onset, projectile vomiting and diarrhoea

Question 436

Describe the clinical picture of cryptosporidium infection (transmission, incubation, symptoms)

Answer 436

• Transmission - animal-human, person-person, contaminated water or land, associated with foreign travel
• Incubation - 2-5 days
• Symptoms - watery or mucoid diarrhoea, severe illness in immunocompromised

Question 437

Describe the clinical pictures of escherichia coli infection (transmission, incubation, symptoms)

Answer 437

• Transmission - contaminated food, person-person
• Incubation - 1-6 days
• Symptoms - haemorrhagic colitis, 5% get haemolytic uraemic syndrome

Question 438

Describe the clinical picture of norovirus infection (transmission, incubation, symptoms)

Answer 438

• Transmission - faecal-oral route, environmental contamination, contaminated food and water
• Incubation - 24-48 hours
• Symptoms - nausea, projectile vomiting, low-grade fever, diarrhoea

Question 439

Describe the clinical picture of clostridium perfringens infection (transmission, incubation, symptoms)

Answer 439

• Transmission - contaminated cooked meat and poultry
• Incubation - 8-22 hours
• Symptoms - diarrhoea, abdominal pain

Question 440

Describe the clinical picture of campylobacter infection (transmission, incubation, symptoms)

Answer 440

• Transmission - raw/undercooked meat, unpasteurised milk, bird-pecked milk, untreated water, domestic pets with diarrhoea, person-person
• Incubation - 2-5 days
• Symptoms - fever, headache, malaise, nausea, diarrhoea, vomiting is uncommon

Question 441

How can food poisoning be prevented?

Answer 441

• Isolation
• Hand hygiene
• Protection e.g. gloves, gowns, masks
• Environmental cleaning
• Respiratory hygiene and cough etiquette

Question 442

What is ‘safe food’?

Answer 442

Food that will not cause harm to a person who consumes the food when it is prepared, stored and/or eaten according to its intended use

Question 443

What are concerns with food?

Answer 443

• Food borne illness
• Nutritional adequacy
• Environmental contaminants
• Pesticides
• Naturally occurring contaminants
• Food additives

Question 444

What does the public health act state about food poisoning?

Answer 444

Allows exclusions from work of people that pose increased risk of GI infection spread - children in nursery/pre-school, people who work with food, health and social care staff, people with doubtful hygiene.

Question 445

What are some of the offences under the food safety act (1990)? (3 examples)

Answer 445

• The sale of food that has been rendered injurious to health, is unfit for human consumption or is so contaminated that it would not be reasonable to expect it to be used for human consumption
• The sale of food which is not of the nature or substance or quality demanded by the purchaser
• The display of food for sale with a label which falsely describes the food, or is likely to mislead as to the nature or substance or quality of the food.

Question 446

What is hazard analysis critical control point?

Answer 446

• Analysis of the potential food hazards in a food business (e.g. microbiological, chemical & foreign matter contamination)
• Identification of the points in the operations where such hazards could occur
• Deciding which of the identified points are critical to food safety (critical points)
• Identifying and implementing effective control and monitoring procedures at the critical points
• Reviewing the hazards and critical points at periodic intervals and particularly when any change occurs to the operation

Question 447

What are the objectives in food poisoning outbreaks? (3 objectives)

Answer 447

• Reduce the number of primary and secondary cases
• Reduce the harm consequent on the episode
• Prevent further outbreaks

Question 448

What are the investigations done in food poisoning outbreaks?

Answer 448

• Preliminary phase - is there an outbreak? confirming the diagnosis, what is the nature and extent of the outbreak?
• Immediate steps - who is ill? how many? case finding; what is the cause? is proper care being arranged? what immediate action can be taken?

Question 449

What are outbreak outliers?

Answer 449

• Outliers are cases at the very beginning and end that may not appear to be related
• First check to make certain they are not due to a coding or data entry error

Question 450

What might outbreak outliers represent? (6 examples)

Answer 450

• Baseline level of illness
• Outbreak source
• A case exposed earlier than the others
• An unrelated case
• A case expose later than the others
• A case with a longer incubation period

Question 451

How can analytical epidemiological studies be useful to identify probable food source of outbreak?

Answer 451

• Compare food history of ill and well persons
• Point source outbreak - cohort study
• Common source of outbreak - case-control study

Question 452

Which GI cancers are prevalent in which populations?

Answer 452

• Oesophageal - Middle East and Chine
• Gastric - Russia
• Colon - ‘Western’ countries, e.g. USA, UK

Question 453

What dietary intake increase the risk of colorectal cancer?

Answer 453

Fat intake

Question 454

What is the evidence base for ‘5-a-day’?

Answer 454

• Evidence from observational epidemiology that average fruit/veg intake of less than 200g associated with increased risk of cancer, but possibly little additional benefit beyond 400g/day
• Very little evidence that ‘5-a-day’ have impact on cancer

Question 455

Describe the relationship between beta carotene and cancer

Answer 455

• Beta carotene found in fruit/vegetables
• Cohort studies indicated protective relationship against cancer
• However RCT showed beta carotene increased risk of cancer
• Cohort groups had reduced risk due to confounding factors, e.g. increased exercise, reduced smoking, etc.

Question 456

What are the problems with measuring diet?

Answer 456

• Random error - diet varies and difficulties in measurement, people don’t eat the same things everyday and individual consumptions vary significantly
• Homogeneity of exposure - if you only do your studies in the same types of populations they are likely to have similar environments and hence diets, so you are not able to apply results to the population
• Bias
• Confounding

Question 457

What are the different measures of diet?

Answer 457

• Food disappearance data
• Household survey - what do you buy and who eats what?
• Individual surgery - 24 hour recall, food frequency (very open to bias), diet diary, biomarkers (very rarely have this)

Question 458

What are the pros and cons of food frequency questionnaires?

Answer 458

• Pros - captures usual diet and less work to code/complete
• Cons - don’t record actual diet as eaten, overestimates fruit and vegetables, poor measure of energy intake, less flexible

Question 459

What are the pros and cons of diet diaries?

Answer 459

• Pros - records diet as eaten (over limited period), better estimate of energy and absolute intake, more flexible
• Cons - required effort to complete and expensive to code

Question 460

What are the main dietary associations with cancer? (7 examples)

Answer 460

• Oesophageal - alcohol, obesity
• Stomach - possibly salted preserved foods
• Pancreas - overweight, obesity
• Hepatic - aflatoxin contamination
• Colorectal - preserved and red meat, alcohol, body fat
• Breast - alcohol, overweight
• Urologic - high calcium

Question 461

What is the trend of alcohol consumption in the UK?

Answer 461

• Per capita consumption in the UK is lower than many European countries
• however people in the UK start earlier and tend to drink more on single occasions (‘binge drinking’)
• Peak of consumption was 2008 - this is linked with affordability

Question 462

What percentage of men and women have an alcohol use disorder?

Answer 462

• 38% of men and 16% of women (16-64) have an alcohol use disorder (approximately 8 million people)
• 21% of en and 9% of women are binge drinkers - double the recommended daily intake
• 3.6% of the total population are alcohol dependent (1.1 million people)

Question 463

Where is identification and brief advice (IBA) delivered?

Answer 463

Delivered in a range of setting - primary and secondary care but also community setting (pharmacies, community health-oriented events)

Question 464

What specialised treatment is available for alcohol problems? (4 examples)

Answer 464

• CBT - common
• Behavioural approaches - behavioural couples therapy, behavioural self-control for moderation goal
• Motivational interviewing
• Social behaviour and network therapy (SBNT)

Question 465

Which medical conditions are wholly attributable to alcohol?

Answer 465

• Alcoholic liver disease
• Alcoholic neuropathy
• Chronic pancreatitis
• Alcoholic cardiomyopathy
• Alcoholic gastritis
• Alcohol related accidents
• Risk factor for - colon cancer, mouth and oesophageal cancer, etc.

Question 466

What are some of the social consequences of alcohol consumption?

Answer 466

• Death - declining since 2008
• Crime and disorder
• Domestic violence - involved in 73% of cases
• Poor productivity at work
• Absences/sick leave from work
• Family effects - 5 million families deal with problem drinker, arguments, violence, debt, relationship problems

Question 467

What are effective, moderately effective and less effective policies for alcohol related health promotion?

Answer 467

More effective policies:
- Price increases - taxation, minimum price
- Restricting availability - opening times, reducing outlet density, age restrictions

Moderatley effective policies:
- Restricting exposure of young people to adverts
- Treatment - identification and brief advice

Less effective policies:
- Drug and alcohol education
- Mass media campaigns

Question 468

What are the key UK departments involved in alcohol policy? (2 main departments)

Answer 468

• Home office (focus on public disorder)
• Department of health (focus on public health)

Question 469

What was the ‘alcohol strategy (2021)’?

Answer 469

• Minimum unit price policy dropped, multi-buy promotion offers were not banned as suggested
• Local health bodies able to instigate review of licenses
• Double fine for selling alcohol to underage people
• ‘Enforced sobriety’ - 1 year pilots based on US models
• Overview alcohol consumption guidelines for adults
• Alcohol included in NHS health check for adults 40-75

Question 470

What is efficiency?

Answer 470

• Target resources to those activities that give the greatest health gain for the money spent as this will maximise population health gain for the money spent as this will maximise population health gain
• Informing these choices required estimation of value of what is given up when a patient is treated (opportunity cost) and the value of what is gained in terms of improvements in the health of patients

Question 471

What is allocative efficiency?

Answer 471

Investing in healthcare are interventions that are worthwhile

Question 472

What is technical efficiency?

Answer 472

Investing in health care interventions which make the best use of scarce resources

Question 473

What is equity in financing?

Answer 473

• Geographic allocation of funding by weighted capitation
• Resourcing determined by population weighted by need

Question 474

What is the class equality/inequality in health care?

Answer 474

Evidence of social class equality in the use of primary care and social class inequality in the use of secondary care

Question 475

What is the concept of the ‘margin’?

Answer 475

The incremental change in resources (inputs and their cost) committed to an activity that produces an incremental change in effects (improved patient outcomes)

Question 476

Why is the margin important?

Answer 476

• Incremental investments in an activity may be associated with diminishing returns
• i.e. successive increase in activity (inputs) yield declining benefits to the patient, or the more you do, the less they benefit

Question 477

Why do we need economic evaluation?

Answer 477

• Values both inputs (opportunity costs) and outputs (health outcomes) of any intervention
• Assess if changes in resource allocation are efficient
• Important because increasing healthcare expenditure needs best outcome for the money e.g. NICE

Question 478

How do you measure cost?

Answer 478

• Cost to NHS - NICE perspective, cost of drug, cost of delivery
• Cost to patient, carers, and society - lost working days

Question 479

How do you measure benefit?

Answer 479

Health gain = increase in length + QoL

Question 480

What is cost-minimisation analysis?

Answer 480

Chooses cheapest option between treatments that have identical outcomes

Question 481

What is cost-effective analysis?

Answer 481

• Costs and outcomes are combined into a single measures e.g. reduction in blood pressure
• Allows comparison between treatments in the same therapeutic area only

Question 482

What is cost-utility analysis?

Answer 482

• Combines multiple outcomes into a single measure (QALY) using QoL instruments e.g. EQ5D
• Allows comparisons between alternatives in different therapeutic categories e.g. CV and cancer

Question 483

What is cost-benefit analysis?

Answer 483

Puts cost and benefit into monetary/numerical terms, e.g. how much is the 3 months gained worth to the patient?

Question 484

When can cost-effectiveness analysis be used?

Answer 484

• If the outcome measures are just clinical
• If other more generic outcome measures are used, use cost analysis to get QALY (NICE use it)

Question 485

What are the levels of resource allocation decisions?

Answer 485

• Macro (societal) level - regarding health funding vs education or funding of certain drugs
• Micro (clinical) level - individual decisions regarding care of individual patients

Question 486

What are the arguments for and against age-based rationing being applied to macro-level resource allocation decisions?

Answer 486

• For - treatment and care of elderly people is very costly so ‘cost-effective’ argument might require resources elsewhere
• Against - most of the elderly burden relates to cost of illness and incapacity rather than age, young person with chronic/serious disease could also cost the same amount

Question 487

Describe the Fair-innings argument (1997)

Answer 487

• Older people had a long life already, therefore fairer to divert resources to younger people
• Elderly also have a disproportionate share of the available resources allocated to them

Question 488

What are the contraindications to the Fair-innings argument?

Answer 488

• treating on the basis of need might mean older people don’t receive lower priority
• Years of life saves shouldn’t matter, the quality of life is more important e.g. QALYs
• Fairness is not the only thing that matters, other things do too e.g. equals treatment

Question 489

What is age discrimination?

Answer 489

Unjustifiable difference in treatment based solely on age

Question 490

What is the difference between direct and indirect age discrimination?

Answer 490

• Direct - direct difference in treatment based on age, cannot be justified
• Indirect - neutral provision or practice that has harmful repercussions on a person based on their age

Question 491

What is the GMC and laws view on age discrimination?

Answer 491

• GMC - must not unfairly discriminate against patients or let views about patient affects decisions
• Law - equality act 2010, protects age, race, sex, gender, disability, religion, etc.

Question 492

How do calculate QALY?

Answer 492

• Assign a utility value (0-1) to a state of health and then multiply by the number of years expected to live in this state

EXAMPLE:
0.5 QALY points x 5 years = 2.5 QALYs
0.8 QALY points x 5 years = 4.0 QALYs

Question 493

What leads to utilitarian justification?

Answer 493

QALYs focus on overall likely outcomes of resource allocations

Question 494

What type of healthcare do you have when the cost per QALY is low/high?

Answer 494

• Low - high priority, efficient health care
• High - low priority

Question 495

What are the arguments for QALY-based assessments?

Answer 495

• Maximises healthcare based on quality and quantity of life
• Considers individual patient level when informing decisions about whether or not to proceed with an invasive procedure based on QALYs they are likely to gain

Question 496

What are the arguments against QALY-based assessments?

Answer 496

• Difficulties in measuring - how do you measure quality or value or life? who makes the decisions? introduces bias
• Can seem unjust - can favour life years over individual lives

Question 497

What is relationship between age and QALY?

Answer 497

• The older you are the fewer QALYs you will gain due to lower life expectancy & co-morbidities
• Doesn’t aim for ageism but it is still discriminatory (indirect)

Question 498

What body appraises medical technologies in pounds per QALY?

Answer 498

NICE

Question 499

What are the 3 discrete steps in critical appraisal?

Answer 499

• Are the results of the study valid?
• What are the results?
• Can I apply the results to

Question 500

What is study validity and what should you look for?

Answer 500

Study validity is the believability or credibility of the results
- Do these results represent an unbiased estimate of the treatment effects?
- Have they been influenced in some systematic fashion to lead to a false conclusion?

Question 501

What are the different types of results?

Answer 501

• Therapy - look at relative risk reduction, absolute risk reduction, odds ratio, number needed to treat, confidence intervals
• Diagnosis - look at sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios
• Prognosis - look at how likely the outcomes are over time and how precise the prognostic estimates are (relative risk or odds ratio)
• Harm/aetiology - look at relative risk, odds ratio, number needed to harm

Question 502

How should you apply the results of a critical appraisal?

Answer 502

• How similar are the patients to the study to your patient?
• Can the local healths service provide the intervention/diagnostic test?
• What are the benefits and costs?

Question 503

How is randomisation done?

Answer 503

• Enveloped
• Computer system

Question 504

How can RCTs be blinded?

Answer 504

• Blind - patient doesn’t know which group they are in
• Double blind - patient and researchers don’t know which group patient is in
• Triple blind - patient, researchers and monitoring committee don’t know who is in which group

Question 505

What is the intention treat analysis?

Answer 505

All patients who were enrolled and randomly allocated to treatment are included in the analysis and are analysed in the groups to which they are randomised

Question 506

What do cohort studies look at?

Answer 506

Looks at population and assesses their risk factors and evaluates who gets disease over time - observational study (can be retrospective)

Question 507

What are the advantages of cohort studies?

Answer 507

• Good for rare risk factors
• Can assess multiple risk factors at once

Question 508

What are the disadvantages of cohort studies?

Answer 508

• Expensive
• Time consuming - risk factor may take decades to cause disease
• Confounding factors

Question 509

What do case-control studies look at?

Answer 509

Looks at group of individuals with a disease and matches them to those with similar demographics - observational study (retrospectively)

Question 510

What are the advantages of case-control studies?

Answer 510

• Good for rare disease
• Good for tracing source of an outbreak

Question 511

What are the disadvantages of case-control studies?

Answer 511

• Recall bias
• Inferior to cohort

Question 512

What should systematic reviews have in their inclusion criteria?

Answer 512

• Papers that have not been published
• Papers that are not in English

Question 513

What are the benefits of systematic reviews?

Answer 513

• Include ALL the available evidence to answer a question
• Include research that is unpublished or published in non-English language journals
• Increase the total sample size (and so increase certainty and precision)
• Permit sub-group analyses
• Permit sensitivity analyses