C3 Flashcards
Criteria for sectioning
3 people must agree that:
- You are suffering from a mental disorder
- You need to be detained for assessment and treatment
- It is in the patient’s best interests or protects the safety of patients or others
Calman-Hine Report 1995 recommendations
All patients need to have access to a high quality of care.
Public and professional education into the early signs of cancer.
Patients, families and carers to be given clear information about the treatment and outcomes.
Cancer care should be patient centred.
Primary care is the central focus of cancer care.
Psychological aspects need to be recognised.
Cancer registration and monitoring.
Commitments and recommendations made to improve cancer care and reduce cancer.
- Lower smoking rates.
- Reduce waiting times.
- 5 fruit and veg a day.
- National school fruit scheme: free piece of fruit for children 4-6 at school.
- Raise public awareness.
- Cancer screening Increased funding for palliative care nurses and MacMillan nurses Investment in staff and equipment.
- Cancer networks to improve experiences.
- Extra funding for hospices.
- End postcode lottery: NICE recommended drugs available to all health authorities
Cancer registries
- 4 in the UK (england, scotland, wales, northern ireland)
- Responsible for registering all cancer that occur in their population.
- Prime aim to establish incidence and survival.
- Identify all new cases and follow them through to death.
- Allows comparison of incidence in different regions.
- Allows researchers to examine long term outcome provides inform on cancer epidemiology.
Ways to restrict alcohol consumption
Primary prevention:
- Minimum unit price for alcohol.
- Raise public awareness
- Clear unit information on alcoholic drinks
- Lower recommended limits
- Stop special offers
- Stop advertising to young people
Secondary prevention:
- Identify problem early: AUDIT, CAGE
Tertiary prevention:
- Offer interventions for alcohol dependence/abuse.
- Alcohol liaison nurses
Types of studies good for treatment
RCT
Systematic reviews of RCT
Number needed to… harm, treat benefit - meaning
- Interventions have both NNT harm and treat.
- Think about: comparison, time period, baseline risk.
- When calculating NNT harm round down!
- When calculating NNT treat/benefit round up!
In secondary prevention, absolute risk difference is larger -> NNT smaller than in primary prevention –> fewer people need to take meds for one to benefit.
Longer time period increases risk therefore NNT decreases when compared to shorter time period.
Population attributable risk
Takes into account relative risk associated with a brisk factor as well as prevalence of this risk factor in the popular
Types of studies good for aetiology
Cohort study:
- Longitudinal study that follow a population, often one that has a particular exposure, e.g. smoking.
Case-control study:
- Population study in which two existing groups differing in outcomes are identified + compared based on basis of some supposed causal attribution.
Types of studies good for diagnosis
Cross-sectional analytic study.
Observational study that analyses data from a population at a specific period of time.
Types of studies good for evaluation
Qualitative research
Systematic review/meta-analysis.
Types of studies good for prognosis
Cohort
Treatment fidelity
How accurately the intervention is reproduced from a protocol or model.
Randomisation
Purpose is to ensure that any confounding characteristics are equally distributed between the two study groups, avoiding selection bias.
Internal validity
How well study was conducted, taking confounders into account. Removing bias.
External validity
Generalizability
How well the study can be applied to different scenarios, patients, environments.
List 5 types of biases.
Selection:
- Error in assigning individuals to groups, leading to differences in groups qualities that may influence the outcomes.
- Reasons;
> Sampling: selected subjects not represented of population.
> Volunteer: volunteer subjects not representative of population.
>Non-responder: responders are not representative of the population.
Recall:
- Difference in accuracy of recollection of study participants;
- Could be due to time, e.g. forgotten.
- Could be influenced by motive, e.g. pt. with mesothelioma may try harder to remember asbestos exposure.
- Particular issue in case-control studies.
Publication:
- Failure to publish/include certain studies because they have negative results=important in systematic reviews.
Hawthorne effect;
- Group changing its behavior due to knowledge it is being studied.
Procedure bias;
- Subjects in different groups receive different care, other than just the intervention.
- E.g. trial with some procedures may result in more human contact.
List 5 types of biases.
Selection
Recall
Publication
Hawthrone effect
Procedure effect
Bias
Systematic introduction of error into a study that can distort the results in a non-random way.
All research has some bias, good studies attempt to reduce this as much as possible.
Advantages of cohort studies
- Best information about causation.
- Able to examine multiple outcomes.
- Good for rare exposure.
- Yields true incidence rates and allows relative risk calculations to be made.
- Best for common outcomes.
Disadvantages of cohort studies
- Long follow up: expensive + time-consuming.
- Bad for rare outcomes.
- Bad for long latency periods.
- Can have different follow-up for exposed/non-exposed.
- Confounders not recognised.
- Usually requires large sample size.
- Cannot determine odds ratio.
Advantages of case-control studies
- Simple/easy/cheap/quick to conduct
- Don’t require long follow ups.
- Best for rare outcomes.
- Good for long latent periods.
- Yields odds ratio
- Can assess multiple exposures
Disadvantages of case-control studies
- Bad for rare exposure.
- Selection of controls may be difficult.
- Controls may not represent where sample is from.
- Cases don’t represent full disease spectrum=cured/died.
- Relies on recall or existing records (recall bias + problematic when records not accurate).
- Confounders not recognised.
Which measures, measure occurrence?
- Incidence
- Cumulative incidence
- Prevalence
- Point prevalence
- Period prevalence
Which measures, measure association?
- Risk difference
- Number needed to treat
- Number needed to harm
- Risk ratio
- Relative risk reduction
- Odds ratio
- Hazard ratio
Which measures, measure population impact?
- Attributable fraction among the exposed.
- Attributable fraction among the population.
- Attributable fraction among the unexposed.
Which measures, fit in the other category (don’t measure occurrence, association or population impact)?
- Clinical endpoint.
- Virulence.
- Infectivity.
- Mortality rate.
- Morbidity.
- Case fatality rate.
- Specificity and sensitivity.
- Likelihood ratios.
- Pre and post-test probability.
List the 4 principles of biomedical ethics.
Autonomy – the autonomous individual freely acts in accordance with a self-chosen plan.
Beneficence – the prima facie moral obligation of all doctors. Best interests are not limited to best medical interests but also encompasses medical, emotional and all other welfare issues.
Non-maleficence – do not cause harm.
- Bolam test – a Dr is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a reasonable body of medical men skilled in that particular art.
Justice – Treat all patients fairly with equity.
Bolam principle
Bolam principle: a principle that establishes whether an act or omission by a HCP breached the duty of care, and thus they were negligent.
Defined not negligent if there is an established body of professionals supports the act, even if the practice was not standard care (e.g. guidelines).
Bolitho test;
- Adaptation of the bolam principle.
- States courts can’t just accept what professionals say, must consider if is logical first.
Bolitho test?
- Adaptation of the bolam principle.
- States courts can’t just accept what professionals say, must consider if is logical first.
Stigma
Stigma: mark of disgrace associated with a particular circumstance, quality, or person.
Processes of producing stigma: Labelling, Stereotyping,
Othering, Stigmatisation
Types of stigma;
- Felt: shame you feel as a result of stigma, may be due to your condition. Can result in pt. not disclosing information (passing), very relevant to health conditions like addiction=may act as a barrier to health-seeking advice.
- Withdrawing: can worsen health conditions. Covering and hiding it can exacerbate sense of stigma –> worsen health conditions, may also prevent friends/family from noticing,.
- Enacted:discrimination by others.
- Courtesy: felt by someone who is with someone else who is being stigmatised.
Labelling
Distinguishing differences between people
It’s an example of a process of producing stigma.
Stereotyping
Making assumptions based on those differences
Othering
Separates person, e.g. diabetes, diabetics
It’s an example of a process of producing stigma.
Stigmatisation
To set some mark of disgrace or infamy upon
It’s an example of a process of producing stigma.
Felt stimga
Felt stigma (internal stigma or self-stigmatization) refers to the shame and expectation of discrimination that prevents people from talking about their experiences and stops them seeking help.
Enacted stigma
Enacted stigma (external stigma, discrimination) refers to the experience of unfair treatment by others
Courtesy stigma
Felt by someone who is with someone else who is being stigmatised
Internal vs external stigma.
Felt stigma (internal stigma or self-stigmatization) refers to the shame and expectation of discrimination that prevents people from talking about their experiences and stops them seeking help.
Enacted stigma (external stigma, discrimination) refers to the experience of unfair treatment by others
Why is felt (internal) stigma bad?
Can result in pt. not disclosing information (passing), very relevant to health conditions like addiction, this may act as a barrier to health-seeking advice.
Withdrawing - can worsen health conditions.
Covering - hiding it can exacerbate sense of stigma thus worsen health conditions, may also prevent friends/family from noticing,.
Equality act 2010 - stigma
Makes it illegal to discriminate directly or indirectly against people with mental health problems in public services and functions, access to premises, work, education and transport
Section 2 Mental health act 1983
- Detained in hospital for ASSESSMENT and treatment
- Up to 28 days
- Can’t renew but can transfer to section 3
- Patient CANNOT refuse treatment
Section 3 Mental Health Act 1983
- Detained in hospital for TREATMENT
- Up to 6 months
- Can be renewed - 6m-6m-12m
- Patient cannot refuse treatment
Section 4 Mental Health Act 1983
- Emergency situations
- Detained for ASSESSMENT
- Only needs recommendation of one doctor
- Up to 72 hours
- Patient can refuse treatment
Section 5(2) Mental Health Act 1983
- Doctors holding power
- Detained from leaving hospital
- Must already be in hospital for treatment
- Up to 72 hours, not renewable
- Patients can refuse treatment
Section 5(4) Mental Health Act 1983
- Nurses holding power
- Detained from leaving hospital
- Must already be in hospital for treatment
- Up to 6 hours, not renewable
- Patients can refuse treatment
Human rights that conflict with mental health act
Article 2 - right to life (authorities must make every protection to protect your life, if death under section = coroner’s report)
Article 3 - Prohibition of torture and inhumane or degrading treatment
If patient disagrees with treatment, independent psychiatrist agrees then not breaking article 3. Restraint is not torture unless done other than for protection
Article 5 - right to liberty and security. Limited liberty if section
Right to education - if a child is detained, they must get education
Common Law regarding detainment is used until the mental health can be put into place
- Right to detain a person if the person is at right to self or others
- Right to restrain with reasonable force (no more than necessary)
- If patient cannot consent: done in best interests
- Treatment must be body recommended
Leventhal’s self-regulatory model of illness behaviour
Representation of a health threat depends on
- Patient interpretation: symptom perception, social messages
- Coping mechanisms
- Appraisal: is coping effective
These all determine the emotional response to a health threat
5 areas of illness representations
- Identity: symptoms, signs, labels and diagnosis
- Cause: perceived causes
- Consequences: perceived physical, social, economical etc
- Timeline: perceived timescale
- Control or cure
Patient may not match the clinician
Method of quantifying patient belief on disease
Illness perception questionnaire
Coping strategies and groupings
Problem focused: seeking new information, practical support, learning new skills, new interests, actively participating in treatment
Emotion focused: sharing feelings, expressing anger in appropriate ways, acknowledging loss, emotional support
Unhelpful: denial, reoccupation with minor issues, blaming
Ways in which patients with learning disabilities are vulnerable
BIOLOGICAL
- Genetic vulnerability
- Brain damage
- Physical disability
- Sensory impairment
SOCIAL
- small circle of friends
- limited opportunities for social interaction
- decreased finance, employment
- decrease support
- at risk of exploitation
- poor housing
- limited choices
PSYCHOLOGICAL
- coping strategies
- low self-esteem
- lack of assertiveness
- feeling helpless
Family support available for those with learning difficulties
Access to family advocacy Family support and info groups Disability support groups Skills training and emotional support Respite care Formal carers assessment
Impact of caring for a mental health patient
- Stress and worry
- Social isolation
- Guilty for taking time for self
- Financial stresses
- Physical health problems - demanding role
- Depression - feeling hopeless
- Frustration and anger - may not have had a choice about being a carer
- Low self-esteem
- Emotion strain - especially if patient attempts suicide
- Patients with mental health are unpredictable and therefore challenging to care for
- Stigma from others on behalf of patient - many try to cope alone
- Reduced specialist mental health respite
Epidemiology of suicide
- M>F
- Men choose more lethal methods - hanging, guns
- Women tend to choose poisoning and self-cutting
- Males have higher success rate
- 4500 per year
- Incidence 19 per 100,000 men and 5 per 100,00 women
- Increased in whites and Asians
- Highest in 15-44 years, although elderly also at risk
RFs
- Previous self harm
- Single/widow/divorced/separated
- Prisoners
- Vets/doctors/pharmacists/farmers
- Immigrants/refugees
- Recent life crisis
- Victim of abuse
- Mental illness
- Chronic physical illness
Epidemiology of self harm
- F>M
- 1-4% of adults
- 10% of 15-16 year old girls
- Highest in adolescents and college students
- Increased in South Asians
RFs
- Borderline personality disorder (70% self harm)
- MH: depression, bipolar, schizophrenia, drug and alcohol misuse
- Domestic violence
- Eating disorder
- Armed force veterans
- Prisoners
- Asylum seekers
- Victim of abuse
- Gay/lesbian/bisexual
Members of community mental health team and their roles
Community psychiatric nurse (CPN) - facilitates treatment plan and monitors progress
Social worker - housing and benefits, make the most of available services
Clinical psychologist - delivers CBT
Psychiatrist - diagnoses and develops care plan
OT - maintain own skills and develop new ones. Back to work. Keep up motivation
Pharmacist - advice on meds
Admin staff - first point of call, arrange appointments
Counsellor - taking treatment and developing coping strategies.
Barriers to rapid diagnosis and treatment of MI
Symptoms - large variation between patient’s
Patient decision time
- Shorter in men than women (women tend to be atypical)
- STEMI has shorter time as more severe presentation
- Increase education to decrease time
Symptom recognition: men more likely to realise MI
More likely to use ambulance if
- Educated about MI
- Increase symptoms severity
- STEMI
- Increased age
- Increased distance to hospital
Hospital:
- Prehospital ECG, and meds decreases time to treat
- Incorrect level of triage
- Busy ER
Outcome indicator vs Process indicator
Outcome indicator:
- Describes the effects of healthcare on the status of the population
- e.g. proportion with surgical site infection
Process indicator:
- Measures what is actually done in the giving and receiving of care.
- e.g. number of patients receiving the correct antibiotics
Advantages of publicly available performance indicators
Patient choice
Patient’s want the information
Increased transparency and openness
Managers more likely to focus on quality than cost
Ensures accountability of staff/ providers of care
Identify areas for concern and improvements
Disadvantages of publicly available performance indicators
Only focussing on measured activity
Lose sight of long term outcomes
Avoiding new approaches in fear of worse outcome
Altering behaviour to gain advantage
- Decreased access to care in high risk patients
- e.g. number treatment with antibiotics in first hour will cause overtreatment of non-cases
Cost of producing information - resource demanding
Patients may not use info
Epidemiology of CHD
1/5 men and 1/7 women will die from CHD More common in males Increase South Asians. Increased in northern England Increased with age
RFs
- Smoking
- Lower socioeconomic group
- Poor diet - high LDL
- Alcohol
- Physical wellbeing: work stress, decreased social support, depression and anxiety
- Hypertension
- Diabetes
- Hypercholesterolaemia
- FHx - 1st degree relative in men under 55 in women under 65
- Obesity
RFs for CVD from highest to lowest importance
Apo-B/Apo-A1 protein (genetic) Current smoker Psychosocial e/g stresses Abdominal obesity Hypertension Daily fruit and veg intake Exercise Diabetes Alcohol
High risk hypertension patients
Patients at a high risk of complications from hypertension
- Older age, men >55, women >65
- Diabetes
- Renal disease/proteinuria
- LV hypertrophy
- Established vascular disease
- CHD
- Stroke
- Peripheral vascular disease
For high risk patients aim for 130/80
Others aim for 140/90
Lifestyle changes to reduce CV risk
Cardioprotective diet
- 5 a day
- reduced refined sugars
- 2 portions of fish a week
- whole grain carbs
Physical activity - 150 minutes of moderate or 75 minutes of high intensity
Lose weight
Reduce alcohol consumption
Smoking cessation
Decreased salt consumption
Health benefits of smoking cessation
Decreased lung and other cancers Decreased CVD risk Decreased risk of COPD and respiratory symptoms Decreased risk of infertility Increased life span
20 minutes: decreased HR and BP 12 hours: CO levels drop to normal 2-12 weeks: increase circulation and lung function 1-9 months: decreased cough and SOB 1 year: half risk of CHD 5 years: risk of stroke that of non-smoker 10 years: half risk of lung cancer 15 years: risk of CHD that of non-smoker
Epidemiology of breast cancer
15% of total cancer patients 31% of female cancer patients Most common cancer in the UK Increased in women Increases with age Highest in Caucasians - western Europe FHx - BRCA gene defect Most common cause of cancer in 15-49 years Most are detected in stage I or II Incidence has been increasing
RFs (separate flashcard)
RFs for breast cancer
COCD
Alcohol
Increased adult height
Ionising radiation
HRT
Raised BMI post-menopause (protective pre-menopause)
History of Hodgkin’s lymphoma, melanoma, lung, bowel, uterus Ca
Benign breast disease
Digoxin
Diabetes
Smoking
Increased birth weight
Increased dietary fat
Increased bone mineral density
Decreased age at menarche
Decreased parity
Increased age at menopause
Increased age at first giving birth
Protective factors for breast cancer
- Breastfeeding
- Hysterectomy / oophorectomy premenopausal
- Physical activity
- Regular aspirin / NSAIDs
- Osteoporosis
- Coeliac disease
Principles of screening
Condition
- Condition should be an important health problem
- Recognisable latent or early symptomatic stage
- Natural history of condition should be understood
Test:
- Simple, safe, precise and acceptable to perform
- Agreed policy on what happens to a patient with positive result
Treatment:
- Effective and more effective if given earlier
- Agreed policy on who to treat
Programme:
- RCT evidence that it is effective at reducing morbidity/mortality
- Benefit outweighs harm
- Cost of screening should be balanced against medical care as a whole
- Facilities for diagnosis and treatment should be available
Define sensitivity
Proportion of patients with the condition who have a positive test result
True positives / true positives + false negatives
Define specificity
Proportion of patients without the condition who have a negative test result
True negative / true negatives + false positives
Define positive predictive value
Chance that the patient has the condition if the diagnostic test is positive
True positive / true positive and false positive
Define negative predictive value
Chance that the patient does not have the condition if the diagnostic test is negative
True negative / true negative + false negative
What needs to be agreed in order for screening program to happen?
Frequency of screening
Ages at which it should be performed
Defined mechanisms for referral and treatment
Information systems that can:
- Send out invitations
- Recall for repeat screening
- Follow patients with abnormality
- Monitor and evaluate the program
Breast cancer screening
50-70 (trial extension from 47 to 73)
Every 3 years
Mammography
Benefits and risks of breast cancer screening
Benefit:
- Allows for less aggressive treatment to be used (early stages)
- Increases prognosis
- Decreased mortality
Risks:
- Pain
- Complications from treatment
- Anxiety (false positives)
- Does not detect 20% of cancers (false reassurance)
- Overdiagnosis and overtreatment
Over diagnosis
A disease that is picked up by screening that would not otherwise have come to attention in that person’s lifetime
Over treatment
Unnecessary medical interventions
- Either due to over diagnosis
- OR extensive treatment for a disease which only requires limited treatment.
Psychological impact of a cancer diagnosis
Employment and income:
- financial hardship
- may have to give up work due to illness/ appointments
Social engagement:
- harder to participate in social events and maintain friendships
- decreased energy and mobility
Change in family dynamics
Emotional distress
Uncertain about unwanted changes to self and life
Feelings - shock, disbelief, fear, anxiety, guilt, sadness
Depression and anxiety
Fertility - can cause infertility
Change in relationships with family and friends
Inability to perform social roles
Changes to sex drive
Changes to body image
Feelings of guilt and self-blame
Factors associated with delayed presentation of breast cancer
Older age Lower educational level Non-white ethnicity Non-recognition of symptom seriousness Decreased social support Presentation type - no breast lump No pain Presence of co-existing morbidity Fear of cancer diagnosis Competing life priorities Embarrassment around breast exam
Effect of culture on psychological response to diagnosis and treatment (breast cancer)
Members of ethnic minorities can often delay in help seeking
Blacks and Hispanics have more advanced breast cancer when detected and have poorer survival rates
Less likely to have mammogram if single, decreased education and unemployed
Increased set backs - unemployment, trouble returning to work, struggle with interpersonal relationships
Differences in knowledge and beliefs regarding cause, symptoms, curability and consequences
Differences in trust in physicians
Some cultures RE male examination worries.
Some cultures stress importance towards families and putting others first
FHx in breast cancer
BRCA1 and 2 gene
Can calculate carrier probability using: BOADICEA or Manchester Scoring system
Refer if:
- 1 1st degree under 40
- 1 1st degree male
- 1 1st degree with bilateral cancer
- 3 2nd degree or 2 1st degree with breast cancer at any age
- 1 1st or 2nd degree with breast and ovarian cancer
Only do genetic screening if mutation risk 10-20%
Prevention of breast cancer in BRCA gene positive
Risk reducing mastectomy
Risk reducing oophorectomy
Chemoprevention- tamoxifen or raloxifene
Role of a post mortem
Examination of a patient after death
Carried out by a pathologist to establish the cause of death or determine effects of treatment
Who is the coroner
Independent official with legal responsibility for the medical-legal investigation of certain deaths including: sudden, unexplained, unnatural or violent in nature
What deaths are reportable to the coroner?
Sudden deaths from unknown causes
Any case where cause of death unknown
Any vehicle, boat, train or plane accident
Any suspicious circumstances
Suicide
If not been seen or treated in last 14 days
Any death within 24 hours of admission
Due to possible negligence, misconduct or malpractice
Any death caused by a treatment or anaesthesia
Any infant death or stillbirth
Death due a crime
Detained under Mental Health Act 1983 or under police custody
Death linked with occupational hazard e.g. mesothelioma, bladder cancer
Due to fall or fracture
Reasons for retaining tissue after post-mortem
Controlled by Human Tissue Authority
- Examined with microscope
- Complex abnormality requiring detailed examination
- Sample may need preparation prior to examination
- Preparation can take weeks
Benefits of post mortem
Provides valuable information on cause of deat
Provides vital info for future treatment/research.
Gives relatives information which may impact on their health.
Data can improve and assess medical care and research - cause and prevention of disease.
Assists in education of doctors and students.
Provides accurate mortality and morbidity stats to improve public health.
Confirmation of death
- Full extensive attempts at reversible causes of cardiorespiratory arrest
Body temp, endocrine, metabolic and biochemical abnormalities
One of the following criteria is met:
- Meets criteria for not attempting CPR
- Attempts of CPR failed
- Life sustaining treatment has been withdrawn
Observe individual for minimum 5 minutes
Primary care
- No mechanical cardiac function: absent central pulse on palpation, absent heart sounds on auscultation
Hospital: one of
- Asystole on ECG
- Absence of pulsatile flow on arterial monitoring
- Absence of contractile activity using echo
Check reflexes to light, corneal reflexes, and motor response to supra orbital pressure
Role of death certificate
Allows relatives to register the death
Provides a permanent legal record of death
Allows relatives to arrange a funeral and settle estate
Provides national statistics regarding cause of death and trends in disease
Given to the next of kin to deliver to the Registrar of Births, deaths and marriages within 5 days who decides if it needs reporting to the coroner
Who can confirm death?
Doctors
Nurses
Suitably trained ambulance clinicians
A doctor’s legal duty is to notify the cause of death, not the fact the death has taken place
Defining death in primary care
Unresponsive patient with temperature over 35 degrees with no drug or alcohol use
- No spontaneous movement
- No respiratory effort
- No heart sounds or palpable pulse
- Absence of corneal reflexes
- Pupils fixed and dilated
Reasons that cannot be used as cause of death on death certificate
Old age Organ failure e.g. renal/heart/liver Mode of dying e.g. cardiac arrest or shock Diabetes Any abbreviations
Epidemiology of lung cancer (not RFs)
3rd most common cancer in the UK
2nd most common cancer in males and females in the UK
13% of total cancer cases
Increases with age
Increased in males
Higher in Caucasians
FHx - yes
87% non small cell lung cancer
13% small cell lung cancer
Most diagnosed in stage 4
RFs for lung cancer
Smoking Low BMI Past cancer (breast, Hodgkin's lymphoma) Asbestos Radon Silica dust HIV Air pollution Ionising radiation Hx of pneumonia, TB, silicosis, COPD Production of coal/coke Organ transplant recipients Diet high in red meet or total fats
Medical conditions that decrease the risk of lung cancer
MS
Coeliac
Parkinson’s
Role of MDT
Bring together staff with necessary knowledge and skills to ensure high quality diagnosis, treatment and care
- Considers patients as whole, not just disease
- Takes into account patients views, preferences and circumstances
- Makes recommendations not decisions
- Final decision is patient and clinician
Effective MDT should result in?
Effective MDT should result in:
- Treatment and care considered by field experts
- Offered opportunity to enter clinical trials
- Continuity of care
- Good communication between 1y, 2y and 3y care
- Good data collection
- Improved equality
- Better adherence to local and national guidelines
- Promotion of good working relationships between staff
- Optimisation of resources
Psychological effects of stoma
- Shock
- Depression or anxiety esp if due to prolonged recovery, long lasting disability
- Alteration in body image - scar
- Alterations in body function - stoma
- Change in daily routine
- Problems with self care and ADLs
- Impact on relationships
- Feelings of embarrassment - sex life
- Rejection from partner
- Altered sleep habits due to fear or leakage, pain or discomfort
- Self- conscious
- Modification of diet
- Employability and insurance issues
Physical side effects of chemotherapy
Fatigue 2y cancer Weight gain Diabetes Ulcers in mouth Anaemia Memory loss Decreased libido Decreased hair Infertility Neuropathy Osteoporosis Renal, liver, lung, cardiac damage Pain Premature aging Early menopause
Psychological effects of chemotherapy
Fear of recurrence Grief Loss of libido Loss of physical dependence Loss of fertility Depression Body image and self-esteem (hair loss) Relationship strain Worry of outside world (increased infection risk) Decreased energy Anxiety Fear of losing job - missing for illness and medical appointments Requiring assistance with ADLs Emotional stresses Financial stresses - decreased work, cost of travelling Feelings of isolation
Reducing cardiovascular disease in community
- Policy approaches: global, national and local
- Healthcare delivery: access to care, quality of care, drugs and technologies
- Heath communication: media
- Determinants: cultural and social norms, health inequalities,
- Identify groups that are high risk
- Assess levels of major preventable causes of CVD
Focus on
- Education
- Schools
- Work
- Environmental change
- Policy change
In what ways can education lower CVD?
- Media emphasising importance of lifestyle behaviours and risk factors
- Public education campaigns to make aware of guidelines for primary and secondary prevention
- Ongoing education of public in CPR
- Guide for prevention, diagnosis and treatment made available
- Limit food advertising to youth
- TV shows for children should promote physical activity
- Teaching in schools
- Compulsory physical education in schools
- healthy school meals
- CPR teaching
What ways can change in environmental factors lower CVD?
- Supermarkets selling fruit and veg at reasonable price
- restaurants offering dishes which meet nutritional guidelines
- Low fat/calorie snacks
- healthy food at check outs
- Support of physical education programmes
- Smoke free areas
In what ways can a change in policy lower CVD?
- Increase unit price for tobacco
- Removal of tobacco advertising
- NHS treatment for smoking cessation
- 5 a day
- 30 mins exercise per day
- Change for life
- No smoking indoors
- Alcohol recommended limits
Levels of evidence
1a - meta-analysis of RCTs
1b - evidence from at least one RCT
2a - evidence from at least one well designed controlled study
2b - evidence from at least 1 other type of well designed studies
3 - well designed non-experimental descriptive studies
4 - evidence from expert committee reports or opinions
Evidence behind dermatological treatments
High levels of evidence for
- PUVA + UVB in psoriasis but is associated with increased cancer risk
- Systemic steroids in eczema (no evidence as to which is the best steroid)
- Little evidence for methotrexate used in psoriasis
- Ciclosporin is the best systemic drug for psoriasis
Dangers of excessive sun exposure
Increased risk of skin cancer
Skin burn - cells and blood vessels are damaged
Heat exhaustion - core temp > 40, sickness, headaches, excessive sweating, feeling faint
Heat stroke - core temp > 40, body cells begin to break down and body functions stop working, organ failure
Vomiting, confusion, hyperventilation, decreased consciousness
Repeated damage leads to premature skin ageing
- Decreased elasticity, dry wrinkled and discoloured
Damage to eyes
UK Mental health services
GP
Community mental health team (CMHT)
Early intervention service (EIS)
Crisis resolution team
Home based treatment (HBT)
Assertive outreach team (AOT)
Day hospitals
In patient units
Improving Access to Psychological therapies (IAPT)
Support groups and charities - Mind, Rethink, SANE, AA, The Samaritans
Role of GP in mental health services
Bulk of treatment done by GP
If referral required usually to community mental health team
Can refer to early intervention service for psychosis
Some patients can present to A&E instead
They will be assessed by a psychiatrist and then referred
Screen and diagnose MH problems
Role of Community Mental Health Team in mental health services
MDT: psychiatrist, mental health social workers, CPNs, psychologists
Co-ordinates patient care
Monitors patients in the community
Initial assessment by psychiatrist then holistic care plan
Role of Early Intervention Service in mental health services
Used to improve short and long term outcomes of schizophrenia and other psychotic disorders
Exclusively PSYCHOSIS at first presentation
- Preventative measures
- Earlier detection of untreated cases
- Intensive treatment and support in early stages of disease
Role of crisis resolution team in mental health services
24/7
Acts as gateway to various psychiatric services e.g. admission
Most common referrals comes form GP, A+E and CMHT
Rapid assessment to determine if admission of home based therapy (HBT)
Role of Home Based Treatment team in mental health services
Short term intensive home based care
MDT as per CMHT
Visits up to 3x per day with gradual decreased
Role of Assertive outreach team in mental health services
For revolving door patients
Reluctant to seek help therefore present at times of crisis
Often have most complex mental health and social problems
Specialist MDT dedicated to engaging them in treatment and providing support.
Role of day hospitals or in patient units in mental health services
If they cannot be safely managed in community
- Patient is danger to self or others
- Requires specialist care or supervised treatment
- Patient lacking social structure
- Carer can no longer cope / needs respite
Most are involuntary / informal
