C2 Flashcards
Why is knowing about decision making important?
- Doctors constantly make decisions.
- Their decisions have effects on patients, their families, society.
- An understanding of decision making, the role of evidence, can help improve medical practice.
What process do doctors use when making diagnoses?
Hypothetico-deductive reasoning
What must an evidence-based decision include?
- Clinical expertise
- Evidence from research
- Patient preferences
- Available resources
What type of decision is a cohort study appropriate for?
Looks at a population and assesses their risk factors and evaluates who gets disease over time
Observational study - Can be retrospective or prospective
- Assessing the effect of a risk factor/exposure
What type of decision are case-control studies appropriate for?
Looks at a group of individuals with a disease and matches them to those with similar demographics
Observational study - Looks back and compares risk factors
What type of decision are RCT’s appropriate for?
- Treatment interventions
- Benefit and harm; cost-effectiveness
What type of decision are qualitative studies appropriate for?
- Patient perspective
- Practitioner perspective
What type of decision are diagnostic and screening studies appropriate for?
Identification
What type of decision are systematic reviews appropriate for?
Summary of evidence for a specific question
Looks at all available evidence and combines the results to determine what the evidence says overall (meta-analysis)
Highest level of evidence
What is evidence based medicine?
Process for identifying and using most up-to-date, relevant evidence to inform decisions for individual patient problems.
Why do we need evidence-based medicine?
- Increasing medical knowledge
- Limited time to read
- Inadequacy of traditional sources of information (out of date textbooks)
- Disparity between diagnostic skills/clinical judgement and up to date knowledge/clinical performance
What is the process of EDM?
- Converting the need for information into an answerable question;
- Identifying the best evidence to answer that question;
- Critically appraising the evidence for its validity, impact and applicability;
- Integrating the critical appraisal with clinical expertise and the patient’s unique circumstances;
- Evaluating our effectiveness and efficiency in carrying out steps 1-4 and seeking ways to improve them.
Types of questions?
Difference between the two?
- Background questions
- Foreground questions
- Background questions are for general knowledge about a disorder, they contain a question root and the disorder.
- Foreground questions are for specific knowledge about managing patients with a disorder. They contain 4 (sometimes 3) essential components. (PICO)
What is PICO?
- Population
- Intervention
- Comparison
- Outcome
E.g. In younger women with breast cancer, is mastectomy with chemo more effective than mastectomy alone, in reducing the risk of cancer recurrence?
After deciding PICO, what is next?
- Identify the best evidence by carrying out a structured search.
- Appraise the identified evidence.
- Integrate the evidence into decision making for the individual patient.
What is the chain of infection?
- Infectious agent
- Host
- Portal of entry
- Mode of transmission
- Reservoir/environment
^ all linked together
Characteristics of an infectious agent/pathogen?
- Ability to reproduce
- Survival (inc. environmental)
- Ability to spread
- Infectivity (ability to cause infection; also colonisation without infection)
- Pathogenicity (severity of the illness)
What is the reservoir/environment?
- ‘Exposures’- don’t forget relationship to lifestyle as a ‘host’ issue
- Animals as reservoirs
- Other humans
- Water systems e.g. Legionnaire’s disease in air conditioning systems
- Environmental contamination
What is the mode of transmission of an infectious agent?
Respiratory spread
- Droplet (3 feet)
- Airborne (suspended particles)
- Plus aerosolization of water
Ingestion
- Direct consumption
- Hand-to-mouth
- Contamination from people
- Contamination from environment
Blood borne
Sexual contact
What are the portals of entry of an infectious agent?
- Mouth
- Nose
- Ear
- Genital tract
- Skin (breakdown of barrier)
What are host factors in the transmission of an infectious agent?
- Chronic illness
- Nutrition
- Age (very young, very old)
- Immunity (immune condition; chemo; transplant etc)
- Lifestyle factors (drugs; alcohol; sex; occupation; poverty; leisure activities)
Define outbreak in the context of infection.
An outbreak of infection is: sudden increase in disease occurrences in a particular time and place
- Some diseases need a sudden increase in a defined area over a short time period
- Some diseases need 2 or more connected cases between space and time
- Some diseases only need 1 case to be considered an outbreak e.g. smallpox
Define pandemic.
An epidemic occurring over a very wide area.
E.g. crossing international boundaries.
Define surveillance.
- Systemic collection, collation and analysis of data
- Dissemination of the results so appropriate control measures can be taken
- POINT OF CONTROL
Define epidemic.
- Occurrence of an illness/ health-related behaviour/ health related event clearly in excess than normal expectancy in a community or region.
- Thresholds define what constitutes them.
- Thresholds decided using info from GPs.
List the common problems of surveilling outbreaks.
- Can look/present similar to other diseases
- Diagnosed as something else/ may not be tested
- Not everyone notifies/ Doctors may forget
- Lab tests may not be routinely available/may take time to come back/ not very good
- Some people may not want to disclose illness
- Potential recall bias in Enhanced Surveillance Questionnaires (ESQ)
- Syndromic surveillance
List common healthcare associated infections (HCAI).
- Norovirus (viral gastroenteritis)
- Carbapenemase producing organisms (CPO) - antibiotic resistance
- MERs-CoV - novel or emerging infections where hospital is amplification point
What can increase risk of having healthcare associated infections HCAI?
- Underlying diseases
- Extremes of age
- Breach of defence mechanisms e.g. IV drip in patient will breach skin
- Exposure to infection
- Hospital pathogens – more resistant
- Antibiotics resistance
How much do healthcare associated infections HCAI cost per year?
Approx £1bn
Different control measures of healthcare associated infections HCAI?
- Hospital environmental hygiene (including isolation of cases)
- Hand hygiene- MOST EFFECTIVE
- Use of PPE (gloves, face mask, googles)
- Safe use and disposal of sharps; and
- Principles of ASEPSIS!
- AB prescribing policy
What is the infection control programme?
- Surveillance of HAIs – MRSA and MSSA bacteraemia and C.difficile infections
- Detection, investigation and control of outbreaks
- Policies and procedures to prevent and control infection
- Dissemination and implementation of national policies
- Education and training
- Monitoring clinical practice
What is global health?
Health of the global population
Improving health and achieving equality in health for all people worldwide
Emphasises transnational health issues, determinants and solutions
What is the motivation for global health?
- Increased awareness of global health disparities.
- Enthusiasm to make a difference across international boundaries.
What is international health defined by?
- Geography (poor nations)
- Problems (infections, water, sanitation)
- Instruments (infection control, Aid, knowledge, medical resources)
- A recipient and donor relationship
What is public health concerned with?
- Prevention
- Equity
- Population-based approaches
- Scientifically validated technical approaches
What is the ‘90/10 gap’ (commission on health research for development - 1990)?
- 90% resources only treat 10% population
- 90% of the world only gets 10% resources
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.
List examples of global issues.
- Global warming
- Development, poverty and inequality
- Food and water security
- Wars and security threats
- Migration
What are the relationship/actors/motivation and main instruments for development aid?
- Dependence
- Donors and recipients
- Charity; self interest
- Discretionary allocations
What are major functions of global health?
- To provide health-related public goods, i.e. research, standards, and guidelines.
- To manage cross-national externalities through epidemiological surveillance, information sharing, and coordination.
- To mobilise global solidarity for populations facing deprivation and disasters.
- To convene stakeholders to reach consensus on key issues, setting priorities, negotiating rules, facilitating mutual accountability, and advocating for health in other policy-making arenas.
What is the goal of vaccinations?
- To reduce mortality and morbidity from vaccine-preventable infections
- Using vaccination strategy adapted to the epidemiology
What is the strategic aim of vaccinations?
- Selective protection of the vulnerable
- Elimination – through herd immunity
- Eradication
What is the programmatic aim for vaccinations?
- Prevent deaths
- Prevent infection
- Prevent transmission (secondary cases)
- Prevent clinical cases
- Prevent cases in a certain age group
What is eradication of an infectious agent?
- Where no other reservoirs of the infection exist in animals or the environment.
- E.g. smallpox or polio
What is the crucial factor determining the spread of infection?
The number of secondary cases caused by each infectious person
What is an example of a conjugated vaccine and when was it introduced?
- HiB
- Meningitis
- Pneumonia
- 1999
What is the R0 proportionate to?
- The length of time the case remains
- Number of contacts a case has with susceptible hosts per unit time
- The chance of transmitting the infection during an encounter with a susceptible host
What is the basic reproduction number (R0)?
- Average no. of secondary infections produced by a typical infective agent in a totally susceptible population
- Doesn’t fluctuate in the short term
- Not affected by vaccination (so it’s not realistic)
- Property of the infectious
agent
When can the R0 differ?
Different infections in the same population
- UK, R0 (measles) > R0 (rubella).
Same infection in different populations
- Measles, R0 (Nigeria) > R0 (UK)
- Reflects population characteristics such as density.
What is the effective reproductive number (R)?
R is the actual average number of secondary cases per primary case observed in a population
Usually smaller than R0
Reflects impact of control measures
- Early stage, R=R0
What is the effective reproduction number (R)?
Average number of secondary infections produced by a typical infective agent in a homogeneously mixing population, where s is the proportion susceptible
R = Ro x s
S = fraction of the host population which is susceptible)
What makes a population susceptible?
Any person not immune to a particular pathogen
Because:
- Never encountered the infection/vaccine before
- Unable to mount an immune response e.g immunocompromised/suppressed
- Vaccine is contraindicated
Using the equation R=Ro x s, with Ro being 10, how many people will an infected person infect, if s is 20%, 10%, 5%?
S = 20%
- R = 10 x 20%
- R = 10 x 0.2
- R = 2 people
S = 10%
- R = 10 x 10%
- R = 10 x 0.1
- R = 1 person
S = 5%
- R= 10 x 5%
- R= 10 x 0.05
- R= 0.5 of a person…
How do mass vaccination programs impact the disease?
- Reduce size of susceptible population
- Reduce number of cases
- Reduce risk of infection in population
- Reduce contact of susceptibles to cases
- Lengthening of epidemic cycle
- Increase mean age of infection
What is the epidemic threshold?
- R= 1
- If R > 1, number of cases increases
- If R > 2, number of cases increases exponentially
- If R < 1, number of cases decreases
- To achieve elimination, must maintain R < 1
How do you work out critical proportion susceptible (s*)?
Threshold at R = 1 defines the s* Therefore - R = Ro x s - 1 = Ro x s - S* = 1/Ro
How do you work out the critical vaccination coverage?
H = herd immunity threshold
H = 1 – S*
Measles in the UK:
H = 95% (s* < 5%)
Once > 5%, thn R > 1
What does the critical vaccination coverage depend on?
Vaccine efficacy
What is herd immunity?
- Level of immunity in the population which protects the whole population
- Only applies to diseases passed from person to person
- Indirect protection to unvaccinated as well as direct effect to vaccinated
What do you need to consider when choosing the best strategy to implement vaccination programmes?
- Risk of exposure
- Risk of disease and complications
- Susceptibility
- Vaccine features: safety, side-effects, efficacy
- Acceptability/ timing issues
What is the role of the WHO in international vaccination strategy and policy?
Makes recommendations for countries on vaccination policy
Supports less able countries with vaccination strategy implementation
Works through the International Health Regulations - “to ensure the maximum security against the international spread of disease with a minimum interference with world traffic”
Give some examples of international immunisation programmes.
- Expanded programme on Immunisation (EPI)
- Global Polio Eradication Initiative (GPEI)
- Global Alliance for Vaccines and Immunisation (GAVI)
Why is international collaboration necessary for imunisations?
- Inequity in access to immunisation services:
- More evident in some of the least-developed countries
- Low political commitment and under investment in some countries may not keep pace with population growth
- Higher costs of service delivery
- R+D may not address the needs of the world’s poorest children
- Lack of commercial incentives for manufacturers to develop new vaccines e.g. HIV/Aids, TB and malaria
- Some countries may not be able to guarantee vaccine quality and safety so: greater risk of poor immunisation practices + children’s lives being put at unnecessary risk
When was the vaccination law introduced in Britain? Did it work?
1889
No, progressive decline in compliance
The British don’t like being told what to do
Name 3 descriptive methods for collecting research population data?
- Case report
- Case series
- Survey
Name explanatory (analytical) methods for collecting population research data?
Can be observational or experimental.
Observational:
- Cross-sectional
- Cohort
- Case-control
Experimental:
- Laboratory
- Trials (RCT)
Which type of studies seek to make comparisons?
Analytical (explanatory)
- They compare experimental vs. observational
- Inference about exposures and outcomes.
Describe case studies (descriptive).
– Report on 1 or a few cases – Usually a rare condition – Limited to ‘real world’ conditions – Any conclusions about cause or outcome are author’s conjecture
Describe case series (descriptive).
– Describe (often unusual) clinical course of condition of interest
– Might provide information about prognosis if cases are representative of all cases
– Again, no direct data but features might help
build hypotheses
What is the difference between prospective vs. retrospective observational studies?
Has outcome occurred before study starts?
• yes = retrospective
• no = prospective
Advantage of prospective
• data quality
• better able to study incidence
List the advantages and disadvantages of experimental studies.
– Investigator can allocate study subjects
Advantages
• stronger evidence of causation
• control of confounders through randomisation
Disadvantages
• limited range of hypotheses
• may not be “do-able”
List the advantages of observational studies.
No allocation of study subjects
• Do not confuse random sampling with random
allocation!
• Observation in a real-world setting
Advantage • Complex web of causation might not be otherwise reproducible – practically – ethically – economically
What are observational studies classified by?
Subject selection:
– Cross-sectional studies
– Cohort studies
– Case-control studies
What are the limitations of cross-sectional studies?
– Only suitable for chronic conditions occurring at a
moderate level in the population
– Only quantifies prevalence of exposure and outcome
• May over-represent factors affecting incidence and duration
• Can confuse protective risk factors
– Reverse-causation
• Best for time-invariant exposures (sex, breed, housing)
• Can confuse procedures implemented in response to disease
What are the pros and cons of cross-sectional studies?
Pros – Representative of population – Potentially efficient – Low cost – Rapid
Cons
– Must verify that risk factor came before
the disease
Describe cross-sectional studies.
Random sample of subjects selected from population.
- Try to represent population in sample.
Simultaneously classify according to:
- Disease status (or outcome)
- Study factor or risk factor
Snapshot.
Describe cohort studies.
Identify subjects:
- With exposure
- Without exposure
Follow the groups through time to determine if disease develops.
Usually prospective.
List pros and cons of cohort studies.
Pros:
– Less susceptible to bias compared to case-control
– More control over quality of data
– No confusion on time order of exposure and disease
– Good for rare risk factors
– Can assess multiple risk factors at once
Cons: – Expensive – Time-consuming – Potential losses to follow-up – Only works for diseases common in a population
Which observational study is usually retrospective and which is usually prospective?
Case-control = retrospective
Cohort = prospective
Describe case-control studies.
– Identify subjects
• with disease
• without disease
– Compare histories of risk factor (exposure)
• Usually retrospective
When is case-control studies used?
Rare diseases
Relatively quick and inexpensive if quality data is accessible.
List pros and cons of case-control studies.
• Pros: – Rare diseases – Potentially efficient – Low cost – Potential for rapid completion
• Cons:
– Highly susceptible to bias related to
selection of controls
What is the WHO recommended herd immunity threshold for mumps?
90% coverage
Individual rights compared to community health in regards to vaccination?
Individual
- Protection by ‘herd immunity’ might be safest option as it avoids risk of vaccine
Community
- Avoidance of vaccine by lots of people will reduce coverage and diminish herd immunity
Basically get vaccinated or you mess up the whole system
What is bad news?
Any news that drastically and negatively alter’s the patient’s or their relatives view of his or her future
Bad if results in “cognitive, behavioural or emotional deficit in the person receiving the news that persists for some time after the news is received
How can bad news be interpreted in psycho-social context?
Social life
- Adolescent dx with diabetes can’t drink
Employment
- Brain surgeon develop tremor due to Parkinson’s, no longer able to work
Financial
- Self-employed, take time off work, lose money, clients etc
Social
- Father with chest pain needing to be admitted, may miss daughter’s wedding, not just affecting him but whole family
What distancing strategies do clinicians use?
- Avoidance
- Normalization
- Premature reassurance
- False reassurance
- Switching
- Jollying along
What may clinicians worry about when breaking bad news?
- Uncertainty about the patient’s expectations
- Fear of destroying the patient’s hope.
- Fear of their own inadequacy in the face of uncontrollable disease.
- Not feeling prepared to manage the patients anticipated emotional reactions.
- Embarrassment at having previously painted too optimistic a picture for the patient.
What 2 mnemonics are there to break bad news?
ABCDE
SPIKES
What is the ABCDE mnemonic?
- Advance preparation
- Build a therapeutic environment/relationship
- Communicate well
- Deal with patient and family reactions
- Encourage and validate emotions
What is the SPIKES mnemonic?
Setting up
- Where, with whom, to whom?
Perception
- What have you been told?
Invitation
- What do you want to know?
Knowledge
- How much do you want to know?
Emotions
- I am sorry/ silence/ validate/ encourage
Strategy and summary
- Follow up plan
What responses to bad news might a patient have?
Basically grief response (can be short or long)
- Anger
- Denial
- Fluctuating mood
- Preoccupation w/ situation
- Agitation/restlessness
- Vegetative signs/symptoms/depression
Define incidence of cancer and incidence rate.
Number of new cases of cancer that occur during a specified time in a defined population
Incidence rate = number of new cases of disease in a period/ number initially free of disease
Define prevalence.
- Burden of disease in a population
- All ongoing cases of disease
- Prevalence = number of people with disease at any point in time / total population
What is important to consider in cancer epidemiology and why?
- Person
- Place
- Time
Important for aetiological hypotheses ( trying to find cause)
Health service planning- if you know how many, you can allocate funds and resources
What are the most commonly diagnosed cancers worldwide?
Lungs
Breast
Bowel
Prostate
Give an example of variation of incidence.
Cervical cancer
- 3rd in Africa
- 7th worldwide
What is the most commonly diagnosed cancers in the UK?
Gender specific
- Prostate in men
- Breast in women
Overall/non gender specific
- Lung
Changes in cancer incidence rates in males?
Increase:
- Malignant melanoma not enough sun protection
- Thyroid tx via radiation for other cancer types
- Prostate active screening and picking up cases that wouldn’t have been before
Decrease:
- Bladder traditionally occupational due to chemical exposure, now more regulation
- Lung
- Stomach
Changes in cancer incidence rates in females?
Increases:
- Malignant melanoma
- Thyroid
- Kidney
- Slight in breast because better screening and detection
Decreases:
- Bladder, ovary, oesophageal and stomach
List examples of varying global incidence rates.
- Cervical –> ^^ in lower income, African countries
- Stomach –> ^^ in China, possibly due to diet or other infections
- Colorectal –> ^^ in westernized high income countries, diet, lifestyle differences
Give explanation for high mortality rates (cancer).
Some present late and lack of available effective treatment
- Lung, pancreas
Some more treatable and number of deaths have gone down but due to high prevalence they’re still big killers
How many people in the UK were living with cancer in 2008?
2 million
Why is incidence and survival increasing?
- Ageing population
- Earlier detection
- Improved tx
How do childhood cancers differ to adult ones?
Histopathologically different
Clinically different
- Tend respond to tx
- Better survival rates
How can epidemiology of cancer help?
Look at patterns to identify causes
Look at reasons for high mortality:
- is it access to care or late stage presentation
- then try and make changes
What is risk transition?
Environmental risk transition is the process by which traditional communities with associated environmental health issues become more economically developed and experience new health issues.
In traditional or economically undeveloped regions, humans often suffer and die from infectious diseases or of malnutrition.
As economic development occurs, these environmental issues are reduced or solved, and people begin to suffer more often from diseases of excess or sedentism.
As a country develops the diseases affecting the population shift from infectious to non-infectious by:
- Improvements to medical care
- Ageing population
- Public health interventions
How many cancer deaths is tobacco associated with?
50-60%
What is pre-disposition vs susceptibility?
Predisposition – due to rare gene mutations predisposing to specific diseases
- Manifest as familial cancer syndromes e.g BRCA1 / 2 or FAP/APC gene
Susceptibility
- Genetic variants that make an individual more susceptible to certain types of cancer and may be linked to specific exposures
What is the difference between primary/secondary/tertiary prevention?
Primary = reduce exposure
Secondary = identify pre-clinical disease and prevent progression
Tertiary = modify outcomes of clinical disease
What is the probability of getting and dying from cancer?
1/3 in lifetime
¼ die from cancer
When was the 5 year cancer survival rates for Britain the worst in Europe?
1980s
1990s
Where was the variation in 5 year survival rates within the UK?
Highest in south
Lowest in north
Causes for poor UK performance?
- Differences in data collection between regions and between the UK and Europe
- Age differences between the populations
- Differences in the stages of presentation – UK patients presented later
- Differences in social class and access to treatment marked socio-economic gradient
When was the Calman-Hine report commissioned?
Why was it commissioned?
1995
Response to evidence of poor UK survival rates in the Eurocare report
What were the Calman-Hine reports main aims?
Examined cancer services in the UK, and proposed a restructuring of cancer services to achieve a more equitable level of access to high levels of expertise throughout the country.
All patients to have access to a 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
What is the role of the MDT?
- Discuss EVERY NEW DIAGNOSIS on their site
- Decide a management plan for each patient and inform primary care
- Develop referral, diagnosis and treatment guidelines for their tumour sites according to local and national guidelines
Who is in the MDT?
Medical staff = physician, surgeon, oncologist, radiologist, histopathologist, specialist nurses
Extended = physiotherapist, dietician, palliative care
When was the NHS cancer plan published?
2000
What were the aims of the NHS cancer plan (2000)?
- First of its kind
- Save more lives through better support, care, access to best tx
- Tackle inequalities in health
- Future investment in staffing, research and genetics of cancer
- Covered aspects of: prevention, screening, dx, tx
What did NICE use the NHS cancer plan (2000) for?
Producing improved guidelines for cancer care
Manual of Cancer Standards
How many people would cancer networks serve?
1-2 million people
What were the key areas of action for the cancer reform strategy?
- Prevention
- Earlier dx
- Better tx
- Better outcomes
- Reduced inequalities
What is the philosophical dualism of the body?
’I have a body’ and ‘I am a body’
Who we are and what we are made of
What contributes to body image?
- Complex
- Parents
- Families
- Communities
- Life experience
- Given guidance in various aspects of life so that we can match self-esteem with our abilities
What do we experience as a dual entity?
- Biological bodies
- Social bodies
What is the concept of physical capital?
- Our bodies give us a sense of certain status/ value
- We can ‘read’ bodies
What is sex?
Biological essence/ determinants of gender
What is gender?
Social differences and identity of men and women
How much faster are eating disorders growing in men than women?
Twice as fast
What has contributed to obesity?
Cheaper food
Especially cheaper unhealthy food
What are body dysmorphic disorders?
A mismatch between the inside and the outside
Or
Subjective and objective body image
What are bodies linked to?
Sense of self and self-status
Any threat to body integrity also threatens this
What are the functions of clinical records?
- Record of contact with health care providers.
- Aide memoire to facilitate communication with and about patients.
- Improve Future Patient Care
- Audit
- Financial planning –> can see changing demographics and disease prevalence –> budgeting for future
- Management
- Research
- Social purposes at the request of patients.
- Medico-legal document —> should always be prepared to defend what you have written in court
What are the medical functions of the clinical record?
Support method of, and structure to, history and examination
Ensure clarity of diagnosis – important in clinical reasoning
Record treatment plans
Enable comprehensive monitoring
Help maintain a consistent explanation for the patient
Ensure continuity of care – another health practitioner needs to read and understand your notes
What do you record in a clinical record?
Presenting symptoms and reasons for seeking health care.
Relevant clinical findings consider any red flags
Diagnosis and important differentials also record any exclusions
Options & decisions for care and treatment record the risks and benefits
Action taken and outcomes
Can be done by hand or computerised
When can you remove information?
If it is duplicated, inaccurate
If patient requests it despite reassurance about confidentiality
Describe the medical records in community care.
Multiple records for different professionals – district nurses, social care etc.
There is limited integration and links to hospitals and GP practices
Single assessment process = for older people, aims to ensure NHS + social services treat elderly as individuals and let them make decisions regarding their care
Describe medical records in secondary care.
Largely paper based
Poor quality of computerisation
Why do you use medical records in audit, research and management?
Facilitates clinical governance, risk management and resource management
Hospitals and GPs have individual standards they must reach
What are the rights of access?
- NHS Code of Practice = only disclose info that you have to and use minimal identifiable info, there is general acceptance amongst patients that info will be shared amongst healthcare workers for optimal treatment
- Common Law of Confidentiality = case by case basis, can breach confidentiality if it is in the public best interest or if instructed legally
- Data Protection Act = data owner and data controller don’t keep records longer than needed and protect them
- Human Rights Act 1998 = respect for private and family life
- Competence to Consent = patients can refuse to disclose info to third parties as long as they are competent
What does critical reflection help you to do?
- Develop skills in life-long learning
- Develop insight and self-awareness
- Develop skills in understanding, analysing and questioning your practice and experiences
- Understand and evaluate perspective of others
- Identify strengths, weaknesses and training gaps
- Writing about experiences or events from which you can learn
- Being open and honest
- Demonstrating a proper understanding of the issues about which you are reflecting on
- Showing an awareness of how your behaviours and those of other people might affect others
- Setting constructive and achievable goals
Why is critical reflection important?
- Understand and evaluate arguments
- To know when to challenge
- To help make the right decisions
- To be able to explain and justify your decisions
How would you evaluate an argument and know whether or not to agree with them?
Step 1
- Is it logical?
Step 2
- Is the argument valid?
- Does the conclusion follow the premise logically?
- If the argument is valid, is it sound?
- Conclusion is only sound if it is true e.g if premises are so bizarre but it could still be valid just not sound
- If answer to both for step 2 is “yes”, then argument is successful
Why might an argument be invalid?
- 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
- Conclusion is being supported by the premise (conclusion is assumed in premise)
Why might an argument be unsound?
- Argument is invalid.
- Argument is valid but one or more premise is false.
- A premise might be false if:
- Makes a false/controversial moral claim
- Makes a false/controversial empirical claim
What should you avoid in an argument?
- The straw man fallacy - misrepresentations
- Ab hominems - evaluate argument based on person who said it
- Appealing to emotion
- Begging the question
- Argument from fallacy - Just because argument is false, doesn’t mean that the conclusion is false, other reasons, just that particular argument that failed
If an argument is unsound, is the conclusion false?
- Even if an argument is unsound, does not mean the conclusion is false.
- Perhaps there are other arguments for the same conclusion or maybe the original argument can be revised in a way that makes the argument more immune to criticism.
- E.g. consider how someone could revise the argument against abortion in a way to block certain objections to premises.
What are the differences between deductive and inductive arguments?
Inductivereasoning moves from specific instances into a generalized conclusion, while deductivereasoning moves from generalized principles that are known to be true to a true and specific conclusion.
Inductive starts with a conclusion e.g tends to be scientific reasoning
Deductive starts with premise e.g tends to be ethical reasoning
What are the different disciplines that testing covers?
Biological tests
- Hb count, Ca2+ levels, ALT levels
Imaging
- Radiographs, ultrasounds, MRIs etc
Questions
- CAGE questionnaire for potential alcohol problems
Examination
- Tactile vocal fremitus, hepatomegaly palpation
Why do we carry out tests?
- To inform decisions
- To confirm what we believe is wrong with patient
What is a true positive result?
The test result is positive in an individual with the disease.
What is a true negative result?
Test result is negative in an individual wo/ the disease.
What is a false positive result?
False positive - result is positive in person wo/ the disease
What is a false negative result?
False negative - result is negative in individual w/ the disease
What does a good test do?
Maximise the true positive and negatives
Minimise the false positive and negatives
What is sensitivity?
Number of true positives/all those with the disease
Tests with a high sensitivity correctly identify a high proportion of individuals who actually have the disease
If 100 patients known to have a disease were tested, and 43 test positive, then the test has 43% sensitivity
What is specificity?
Number of true negatives/ all those without disease
Tests with a high specificity correctly identify a high proportion who really don’t have the disease
If 100 with no disease are tested and 96 return a negative result, then the test has 96% specificity.
What are predictive values of a test?
- Reflect diagnostic power of a test
- So if the test result is positive, what are the chances of the patient actually having the disease
- Or if the result is negative, what are the chances the patient doesn’t have the disease
What is the positive predictive value?
Number of true positives/All those who tested positive
Chance of actually having the disease if result comes back positive
What is the negative predictive value?
Number of true negatives/All those who tested negative
The chance of not having the disease if your test is negative
What is D-dimer?
What does its presence suggest?
Degradation product of fibrin
Clotting has occurred
Its presence suggests DVT/PE
What are the PPV and NPV for D-dimer tests?
And what does this mean?
- High NPV
- Lower PPV
- Good at ruling OUT DVT, as high chance of not having disease if your test is negative
- Not good at diagnosing it
What does disease prevalence affect? Why?
- PPV and NPV changes
- Sensitivity and specificity remain constant
A good test will always correctly identify a certain % of people w/ or wo/ the disease
What happens to PPV and NPV as prevalence increase?
- PPV increases
- NPV decreases
More people with the disease so chance of picking it up are higher
What happens to PPv and NPV when prevalence decreases?
- NPV increases
- PPV decreases
Disease that is more uncommon means there are more people in the population without it, so it is easier to rule out
Where does disease prevalence change?
- Between primary and secondary care populations different
- Across age groups
- Between countries
What is likelihood ratio?
- Another way of summarizing performance
- Assessing value of performing a dx test
- Assess chances of disease after we have performed the test
Use it to work out if it is worth carrying out the test and how much you should shift your suspicion for a particular test result
What is the LR for positive test results (LR+)?
Chance of testing positive if you have disease/ chance of testing positive if you don’t have disease
What is the LR for negative test results (LR-)?
Chance of testing negative if you have disease/ chance of testing negative if you don’t have disease
What is the significance of LR+ and LR-?
The larger the LR+ the greater chance you have disease if your test is positive
The smaller the LR- the less chance you have disease if your test is negative
What is the pre-test probability?
Chances of disease before test = the disease prevalence in your population
Define screening.
Systematic application of a test or inquiry to identify individuals at sufficient risk of a disorder to warrant further investigation or direct preventive action amongst people who have not sought medical attention
What kind of approach is screening?
Population based
Give 4 examples of screening.
- Heel-prick test for congenital diseases
- AAA and ultrasound
- Cervical cancer and smears
- Bowel cancer and FOB
What level of prevention is screening?
- Secondary (most)
- Because detecting early disease allows a potential for early and more effective treatment
Does positive screening = diagnosis?
No
Identifies those who need more dangerous/invasive definitive tests.
What do you need to consider w/ the condition you screen for?
- Should be important justify effort
- Epidemiology and natural history should be understood
- Detectable risk factor
Latent period (asymptomatic identification) - Already have cost-effective primary prevention implemented
What do you need to consider w/ the screening test?
- Simple
- Safe - Especially as exposing WELL people to it, so don’t want people put at risk
- Precise
- Validated
- Consistent
- Have a suitable cut off and have the test value distribution known
- Agreed policy on further management
What do you need to consider w/ the treatment after screening?
- Needs to be effective
- Evidence of early treatment leading to better outcomes
- Agreed policy on who should be offered tx
- Clinical management should be optimized prior to screening programme
What do you need to consider about the screening programme itself?
- RCT evidence it effectively reduces mortality or morbidity
- Evidence ALL aspects are acceptable to professionals and public
- Benefits > harms
- Screening actually harms patients
- Opportunity cost of the programme should be balanced in relation to healthcare spending i.e shouldn’t deny something of greater value
- Must have plan for quality assurance and adequate staffing and facilities
Why do screening programmes need to be put through trial first? What should they not do?
- Selection bias
- Length bias
- Lead time bias
Should not assess survival from point of diagnosis
Define selection bias.
The people who come for screening tend to be healthier than those who don’t e.g. ’health screening effect’
Define length bias.
Screening is best at picking up long-lasting and slowly-progressive conditions rather than rapidly-progressing poor prognostic ones
What is sojourn time and how does it link to length bias?
- Sojourn time is the length of time tumour/disease spends in Asymptomatic/pre-clinical phase
- Short= rapidly progressing –> poorer prognosis
- Long = better prognosis
- More likely to detect diseases with longer sojourn times
- In whole population, there is people with lots of different long and short sojourn time diseases.
- Those who are screened more likely to have long sojourn time because longer period they can be detected
- Hence if you only measure survival from diagnosis you would have a disproportionate number of people with slowly progressing disease compared to normal disease population
- Makes programme look better/more successful than it actually is
What are the consequences of length bias?
- Diseases with longer sojourn time are easier to catch
- Screen-detected disease has better prognosis than people who are symptomatic
- Comparing individuals who choose to be screened with those who have disease = distorted picture
- Basing RCT on ‘intention to screen’ includes full range of outcomes and assess impact of screening
Define lead time.
The time between disease detection and clinical symptoms.
Define lead time bias.
- Survival time after screen-detection appears longer because you start the ‘clock’ sooner
- Additional time added to the length of patients disease due to it being picked up in presymptomatic phase by screening
If we are measuring survival only:
- A screened patient may die at the same time as a non-screened patient
- The screening programme appears to extend survival but in reality all it does is cause the patient to live with the disease diagnosis for a longer period of time
- If the disease outcomes cannot be changed regardless of screening then you are simply adding in additional lead time that is of no clinical importance
What are the consequences of lead time bias?
Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time
How do you appropriately measure screening effectiveness?
Death rates
Thinking about the condition, why does colorectal cancer have a screening programme and not prostate cancer?
Colorectal
- Biology of polyp-cancer progression reasonably well understood
- Polyps/cancers bleed/can be seen
- Primary prevention limited: ?diet, ?aspirin
Prostate
- Biology very poorly understood
- High prevalence of clinically unapparent disease
- Prostate cancer (plus other things) raises PSA in blood
- Primary prevention doesn’t exist
Thinking about the test, why does colorectal cancer have a screening programme and not prostate cancer?
Colorectal
- Sensitivity of FOB (80-90%)
- Specificity of FOB (90-98%)
Prostate
- True sensitivity/specificity unknown
Thinking about the treatment, why does colorectal cancer have a screening programme and not prostate cancer?
Colorectal
- Resection is of proven benefit
- Less advanced stage = better survival
Prostate
- Number of tx options under investigation
- One is ‘active monitoring’ basically no curative tx so the test isn’t justified?
Thinking about the trials, why does colorectal cancer have a screening programme and not prostate cancer?
Colorectal
- Number of trials reported
- Over 20 years from starting trial to implementation
Prostate
- Number of trials in progress
- Initial results reported in April 2009
When thinking about whether to screen for a disease what do you need to assess? (summary)
- Condition
- Test
- Treatment
- Trials
What are the disadvantages of screening?
- Anxiety to patient
- Risk of harm through screening procedure
- Overdetection/overdiagnosis and overtreatment of things that might not have caused a problem in the first place
- Interventions cause side effects and carry further risks
Who does/doesn’t benefit from screening?
True positives
- Some will benefit others won’t
True negatives benefit from less anxiety I guess but not much else
What must be considered w/ reproductive ethics?
Interests of the parents
- Procreative autonomy
Interest of future child
- Welfare of child, will it live poor life either to disability or harm from parents?
Interest of 3rd parties
- State, use of resources, ART can be expensive so this justifies limits on the number of cycles
What are the objections to ART?
Involves destruction of human embryos which have potential to become a child:
- Depends on moral status you assign to embryo, many will agree it is same as human
- Even if same rights, would embryo take priority over mother if it becomes a danger to her health?
It is harmful to those trying to conceive?
- Success rate for IVF is low –> emotional harm?
- Risks of multiple pregnancy –> higher risk of mortality and morbidity
It is ‘unnatural’ and should not be playing God
- Relatively weak
- Much of medicine can be considered unnatural
What is the open-future argument?
Children should be ensured a maximally open future i.e widest possible range of opportunities
- Used as basis to terminate embryos with serious disabilities
What type of right do parents have?
Negative right
- To not be prevented from conceiving a child by the state
Do not have a positive right for state-provided help/ intervention with ART
Basically the State can’t stop parents from having children but it doesn’t mean they have to help them do it
What are the legal aspects of ART?
What act is it laid out in?
Human fertilisation and embryology authority act 2008
- Welfare of child needs to be taken into account
- Need for ‘supportive parenting’ hence valuing role of all (hetero and homo) parents
- Sex selection/social selection of embryos is prohibited
Why has the human fertilisation and embryology authority act been criticised?
Fertile couples don’t need to apply the ’welfare criteria’ why should it just be infertile couples?
Predicting welfare of the child is hard
- There is no guarantee over future circumstances of both the parents and child
- Couples can put on facades to get the treatment
How many ART cycles can 23-39 cycles have for free?
Up to 3
What are other third party interests?
A child born with disability as a result of ART would be a further burden on the state
What is pre-implantation genetic diagnosis (PGD)?
Screening cells from the embryos for detection of genetic/chromosomal disorders
Considered acceptable for screening for genetic diseases e.g mitochondrial disease but not for sex selection/ characteristics
What is the pro-life argument?
Abortion ends life of a foetus and is morally wrong
Foetus has moral status of a human therefore identify it as a human with full moral status and abortion is the same as killing a human
Therefore, It is wrong to kill a person/ creature that has same moral status as a human
What is the pro-choice argument?
Mother has right to exercise control over her own body
An embryo/foetus doesn’t have the same moral status as a fully-grown human
What are the problems w/ moral status?
- Does it have the full status of a human
- What stage does it assume this, conception, development or point of birth?
- Potential to be a human- is it acceptable to assign moral status based on this?
- We don’t treat other things the same e.g we all have the potential to be corpses, but are not treated as such during life
What are the legal aspects of abortion?
- Abortion act 1967
- Amended in 1990
- Not unlawful if 2 medical practitioners think:
- The pregnancy hasn’t exceeded 24 weeks and continuing the pregnancy would have a greater risk of injury to the mother, physical or mental, than if it were terminated
- The termination is necessary to prevent permanent injury to the mother – physical or mental
- Continuing the pregnancy would put the life of the mother at risk, greater than if it were terminated
- There is a significant risk of the child would suffer from physical/ mental abnormalities
Are doctors allowed to refuse participation in termination?
- Yep, they have autonomy
- Except emergencies then they have to whether they like it or not
- However, compromises can be made e.g. referring to another doctor
How do children and adult rights differ?
Same
- Involved in decisions and have confidentiality
Differ
- Different decision-making and vulnerability
Why are children of concern?
- Dependent on others to take care of them
- May have underdeveloped decision-making capacities in terms of understanding
- Undeveloped value systems which makes assessing their best interests difficult
- Possess limited powers- physical, emotion and legal- to defend their rights
What does the GMC state in regards to children?
Young people can be vulnerable, need protecting and help with decisions and defending their rights
Respect rights of young people and their decisions + confidentiality take views seriously
At which age are you presumed competent?
16-17
Must obtain consent
If under 18, you can’t refuse treatments approved by parents or in your best interest
How are decisions made in under 16s?
If Gillick competent, can make own decisions. The must…
- Understand the nature + consequences of treatment/ no treatment
- Retain the info and weigh it up
- Communicate their decisions/ ideas clearly
If not competent, then consent from someone with parental responsibility is sufficient
- Mother/father (married or acquired parental responsibility)
- Guardian of child/local authority
- People with parental responsibility have a legal obligation to act in child’s best interests
What happens if parents don’t consent to Tx in child’s best interest?
Take them to court
What do best interests comprise of?
- Views of the child as far as they can express them
- Views of the parents & others close to the child
- Cultural, religious or other beliefs and values of child & parents
- Views of other healthcare professionals involved in providing care
- The choice that will least restrict child
Define parental autonomy.
Parents should be allowed to make decisions regarding their children.
- Because they know them best
Can be overruled if child’s welfare is at stake.
Complex tx issues = withholding tx, religious/cultural procedures.
Pros and cons of making childhood immunisations mandatory?
Pros
- Favours health of the public by lowering disease incidence
Cons
- Stops people making own choices on behalf of children, risk of harm from side effects
Define the harm principle.
State intervention is justified if it is necessary to prevent greater harm to the public than not intervening.
What do children have a right to be protected from?
- Abuse
- Neglect
- Rights to be involved in own care
Confidentiality in regards to children?
Same as adults, especially to those who are competent
Should ask permission before discussing case with parents
Not an absolute obligation, info can be shared in child’s best interest
When can you provide contraceptive, abortive and STI tx to people under 16 without parental consent?
Only if:
- They understand all aspects of advice and refuse to involve parents.
- Likely to have sex regardless of what you say.
Confidentiality is key lack of it deters people from getting advice they need and thus endanger their own health
If involved in abusive/harmful sexual activity then info should be shared with appropriate agencies.
How many hospital deaths are thought to be avoidable?
6%
List why hospital deaths are thought to be avoidable.
Poor monitoring
Diagnostic errors
Drugs etc
EBM is absent
Pharmaceutical companies don’t publish all trials, makes thorough systematic reviews of all evidence difficult –> lead to disasters e.g Vioxx
Types of medical errors?
Medication e.g incorrect drug, severity depends on situation e.g chemo vs painkillers
Surgery e.g wrong procedure —> WHO checklists
Infection control - what is efficient level of error? Zero?
What was introduced to reduce MRSA and C.diff?
Reporting and penalties
What are ‘never ever’ events?
- Shouldn’t ever happen
- E.g incorrect blood transfusion
- Get penalties and fines
What are patient reported outcome measures (PROMs)?
Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering 4 clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys.
The four procedures are: hip replacements knee replacements groin hernia varicose veins
PROMs measure a patient’s health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires.
This health status information is collected before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients.
Why do we need consumer protection?
Medical practice internationally had 3 deficiencies:
- Medicine overall has a weak evidence base.
- Large variations in clinical practice – we give different treatments to patients who are similar in need.
- Failure to measure success/ outcomes in healthcare – we measure mortality but this is a limited outcome.
What data is available to improve patient safety?
Hospital episode statistics (HES) - Details referring GP, procedures given, duration of stay and discharge/death
Patient reported outcome measurements (PROMs) - compares quality of life before an after procedure
Reference cost data - Cost data are poor
What is the hospital level mortality indicator (2012)?
Mortality rates within 30 days of discharge compared to expected mortality given hospital characters
Need to be adjusted for age and severity of conditions
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
What are the different consumer protection agencies?
- CQC (care quality commission)
- NICE (National Institute for Health and Care Excellence)
- DoH and NHS England - oversight of cost and quality control
- GMC- regulates medical schools and practitioners
- Royal colleges - examine and certify practitioners
What is the role of CQC (care quality commission)?
- Regulates quality and financial performance of all healthcare providers – public and private
- Licensing of all healthcare providers without this cannot trade
- Policing: unannounced visits and inspections use the HES data
Monitor:
- Regulation of finances AND quality of Foundation Trusts only
- Competition policy and hospital tariffs – Pay by Performance
What does NICE do?
- Appraise new technologies
- Produce clinical guidelines
- Advise on cost-effective public health interventions
In what way is family structure changing?
Increasingly smaller, single and step-parenting families
What is the social context of pregnancy and childbirth in a professional and ideological context?
Professional
- Doctors Vs midwives who has authority
Ideological
- Nature Vs technology
- Home Vs hospital
- Private Vs public (pure Vs polluted)
Name some inequalities.
Poverty and income
Poor nutrition - endanger both mother and child
Access to health and social care – varied may not always meet needs
Ethnicity and experience of health inequalities
Internationally
- Niger- maternal mortality is 1 in 7
What is pollution in context of childbirth and pregnancy?
- Many aspects are regarded as ‘polluting’
- Unwashed baby, blood, placenta etc
- There are cleansing practices in some cultures
- Some forbid male practitioners from carrying out internal examinations
- Only recently have men had role in birthing process
What is medicalisation?
The process by which events seen as ‘normal’ in life are overtaken by medical practice.
What are some of the medicalisation that have taken place?
Moved from all female domain to medicalized sphere involving men
Changes:
- Public to private behind closed doors
- Midwife to doctors + nurses
- Natural to medical
- Home to hospital – due to concerns over maternal + infant mortality e.g. Puerperal fever:
- People wanted pain relief and safety – ‘rich’ people were seen as not suffering so others also wanted this, why should others suffer with no support?
- Cleanliness – although not as clean as we think
- Higher status – elitism of having child in hospital
- Being cared for after birth
What was the maternity matters (2009) guideline?
Gives choice to mother about care, continuity of care and safe service
What is the role of midwives?
- Used to just be wise women in the community but then had Royal college established (1947).
- Effect on medical practice = create a ‘home-like’ environment.
- Don’t separate child and mother and include mother in all decisions.
What are the regulations around C sections?
2011 NICE guidelines
State all mothers should be given right to choose a c-section if they wish
Even if there is no clinical indication for one
What are childhood illnesses in lower income countries mainly caused by?
Infection
Name the major childhood illnesses in high income countries?
Injury/poisoning
- 90% accidental
- 20% of all deaths 1-5 yrs
- 1mn + A&E admissions
Cancer
- 20% of all deaths, most child cancer is malignant
CNS diseases
Congenital abnormalities
- 3%
What are the major childhood illnesses in low/middle income countries?
- Diarrhoea
- Pneumonia
- Malaria
- HIV/AIDs
- Measles
- Neonatal disorders
How much of A+E paediatric admissions are a result of falls?
50%
What are the most common childhood cancers?
- Leukaemia
- Lymphoma
- CNS and brain
What is included under perinatal?
- Delivery
- Infection
- Congenital
Name acute CNS illnesses?
- Meningitis
- Meningoencephalitis
- Febrile convulsions – URTI with fever, bilateral convulsion need to distinguish from seizure
- Seizure disorder e.g. epilepsy
- Vascular – AVM causing stroke
- Congenital
Name acute respiratory illnesses.
URTI – tonsillitis, croup (parainfluenza), tracheitis (S.Aureus)
LRTI – bronchiolitis (RSV), asthma
Pneumonia – viral, bacterial, atypical
Foreign body inhalation right bronchus
List acute GI illnesses.
Vomiting:
- Medical = gastroenteritis, GORD, sepsis, food intolerance
- Surgical = pyloric stenosis, malrotation, intussusception
Acute abdominal pain = appendicitis, gastritis etc.
Gastroenteritis
Inflammatory bowel disease
Diarrhoea:
- Infective most common worldwide
- Malabsorption
- Food intolerance
- Constipation = common cause
Significance of UTI under 6 months?
Need ultrasound to look for any structural abnormality e.g horseshoe.
Name common public health measures.
- Seatbelts for accident prevention
- Immunisation
- Antenatal and neonatal checkups and blood spot tests for conditions such as hypothyroidism
Name the common chronic illnesses.
- Asthma
- Epilepsy
- Diabetes
- CF
- IBD
What are the implications of chronic illnesses?
Child = physical, mental, social
Repeated absence at school
Affects parents and siblings
Significant financial for both family and community
National health = provision and planning
How many children are obese and overweight (<5yrs)?
1/6 obese
1/3 overweight
How much of the world’s population live in a country where obesity kills more people than being underweight?
65%
Name the risk factors for childhood obesity.
- Parental obesity
- Gestational diabetes
- Less than 6mths exclusive breastfeeding
- Weaning onto high-fat/sugar foods
- Poor diet + low physical activity
How many deaths under 5 are preventable?
2/3
What is the proportion of all childhood deaths for Africa and South-East Asia?
75%
What were the major causes of death?
- Preterm – 1 million
- Pneumonia
- Diarrhoea
- Malaria
What are the risk factors of death in of under 5s?
- Low birth weight
- Malnutrition
- Non-breastfed children
- Indoor air pollution
What are the preventative measures for death of under 5s?
Vaccination - conjugated vaccine as immature immune system can’t respond to coat adequate nutrition and breastfeeding encouragement
What is the causes of pneumonia in children?
Bacterial
- Strep pneumococcus
- Polysaccharide capsule that an immature immune system can’t fight
Viral
- Resp. syncytial virus is the most common cause of lower RTIs + viral pneumonia
What are RF for diarrhoea in children?
- Non-breastfed
- Unsafe water and food
- Poor hygiene
- Malnutrition- zinc in particular
What are Tx for diarrhoea?
- Oral rehydration salts
- Zinc supplements
What prevents diarrhoea in children?
- Exclusive breastfeeding safe water and food
- Adequate sanitation
- Vaccination
What are the causes of diarrhoea in children?
Gastroenteritis:
- Viral (Rotavirus/Norovirus)
- Bacterial
What is the RF for malaria?
- Young children
- Endemic areas
- Lack of vector control (parasite)
- HIV/AIDs
- Drug and insecticide resistance
What is the Tx for malaria?
- Supportive
- Artemisnin-based combo therapy
What is the prevention for malaria?
- Insecticide- treated nets- v.effective
- Indoor residual spraying
- Chemoprophylaxis in endemic regions
What are the causes for malaria?
- Plasmodium parasite
- Most common (P. falciparum)
When is the highest risk for death?
- Neonatal period
- First 28 days
What is the single largest cause of childhood death?
- Preterm birth
- 10% of all births
What are the short term problems for preterm births?
- Infection
- Resp difficulties
- Feeding problems
- Jaundice
What are the long term effects of preterm birth?
- Neuro-disability e.g cerebral palsy
- Chronic lung disease
- Poor growth
How do you minimise health risk to newborns?
Quality care and nutrition during pregnancy + maternal immunisation
Safe delivery
Quality neonatal care:
- immediate breathing
- warmth care
- early breastfeeding
How many children are affected by malnutrition?
20 million globally
More vulnerable to illness and death
Can be treated at home with ready-to-use therapeutic foods
