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
Role of key worker in mental health services
Usually a CPN or social worker
Co-ordinates and administers treatments
Has knowledge of local services and encourages and allows access
Liase with GP and other agencies
Assists with planning and monitoring of care
Specialist mental health services
General adult Old age Child and adolescent Liaison Substance abuse Forensic Learning disability
Psychiatry
Social and cultural factors contributing to depression
Social support - those with more are less likely to get depression
- Helps to know they are not alone
- Someone pushing them towards getting better
- Strong family network
Decreased socioeconomic group have decreased stability and increased risk of depression
High stress job or environment can worsen depression
Ethnic minorities are at higher risk of depression - immigration status, decreased income and education level
Different populations talk about depression differently and have different help seeking behaviour
Services may not be available in native language
Less likely to seek help for depression if: elderly, young adult, ethnic minority or decreased social support
Financial implications may be barrier to treatment- child care, transport
Stigma is different in different populations
Different groups have different beliefs and preferences RE treatment e.g. CBT/medication
Primary health promotion strategies to increased mental health
- Health visitors for all at risk of post natal depression
- School based prevention of violence, bullying, offending or re-offending
- Screening and brief interventions for alcohol abuse
- Promotion of well being at work
- Supported employment for those recovering from mental health problems
- CBT for those with medically unexplained symptoms
- Suicide prevention
- Early intervention service
- Debt advice
- Anti-stigma campaigns
- Increased focus or social support
- Tackle social and economic inequalities
Political action regarding mental health problems
Public Health White Paper
- Tackle substance addiction through minimum alcohol pricing policy
- Promote public health interventions to prevent future inequalities
- Ensure suicide prevention strategy
- Prioritise mental health within smoking cessation
- attended to discrimination and stigma around MH (time to change)
- Target public mental health interventions for high risk people: cared for children, unemployed and homeless
- Promote importance of MH and well being
RFs for chronic liver disease
Hepatitis
- Travel to high risk areas
- IVDU
- Male homosexuality
- Healthcare worker
- Tattoos and piercings
- Blood transfusions
Alcohol Medications FHx Obesity Metabolic syndromes Heart failure
Methods for prevention of chronic liver disease
In high risk areas - wash hands, no salad or ice
IVDU - needle exchange programmes
Condoms
PPE at work.
Tattoos and piercings only though registered practices
National screening of blood transfusions
Recommended alcohol limits: 14/ weeks, 2 free days
Promote MH to decrease Paracetamol OD
Drs aware of drug interactions
Obesity: national health eating, change for life. increase exercise programmes
In metabolic syndromes: control diabetes and weight
Physical problems associated with dialysis
Not treated daily so can feel tired and nauseous between treatments
Gain fluid weight between sessions
Must limit fluid intake and diet strictly
Pain and discomfort
Additional for PD:
- Increased risk of peritonitis
- Problems with sleep and rest
Psychosocial issues associated with dialysis
Difficulty arranging transport
Difficulty managing a fixed schedule around other plans
Difficulties with going on holiday - need treatment while there
Alteration in marital, social and family relationships - may develop carer role
Feelings of loss of personal control
Increased anxiety and depression
Uncertain future, large demands of illness
Dependence on machinery, medication and healthcare
Loss of freedom (less with PD)
Feelings of frustration
Decreased quality of life
Impaired self and body image
Impact on sexual activity
Feeling like a burden
Impact of mental health on primary care
COMMON
Large range of conditions seen by GP: adjustment reactions, anxiety, depression, schizophrenia, bipolar disorder, addiction
90% of MH problems are managed by GPs
GPs only receive 10% of MH funding
30% of GP visits have a mental health component
30% will have sick leave due to MH problems
Patients with MH problems have more consultations regarding physical problems Increased use of services Increased cost Decreased appointments available In 10 minute appointments: - Difficult to spot a problem - Run late if more than 1 problem or brought up last - patient dissatisfied if rushed
National Framework for Mental Health 1999
- Primary care to care for common mental health problems
- Primary care to contribute to health promotion
- Lack of clarity regarding management of complex, chronic and disabling non-psychotic problems
- GPs require good understanding of healthcare needs in these patients
Types of living organ donation
- Directed donation
- Direct altruistic donation
- Non directed altruistic donation
- Donor chain
Describe a directed organ donation
Living organ donation
Health person donates organ to a specific person where there is a relationship between them
Describe a directed altruistic organ donation
Living organ donation
Donation to specific individual but no evidence of genetic or emotional relationship between donor and recipient
Describe a non directed altruistic organ donation
Living organ donation
Health person donates organ to unknown recipient matched by NHSBT
Describe donor chains in organ donation
Living organ donation
Non directed altruistic donors can donate into paired or pooled scheme
Match 2+ donors to recipients and the organ at the end of the chain goes to best matched NHSBT patient on list
- Occurs when donor can’t donate to friend/relative as they are not a match
- Enter a pool, when friend gets a kidney, they donate theirs
Legislation covering organ donation and tissue removal
Human Tissue Act 2004
Human Tissue Act 2004
Covers England, Wales and Northern Ireland
Established the Human Tissue Authority to regulate activities concerning removal, storage, use and disposal of human tissue
It governs consent for storage and use of organs taken from living person for transplantation
Consent for removal is under Mental Capacity Act 2005
All living donors must be approved by HTA before hand
Criteria from HTA for living organ donation
- No reward has or is to be given
- Consent for organ removal for transplant has been given
- Independent assessor has conducted separate interviews with donor and recipient and submitted a report to HTA
- Report is sent to HTA approvals team
Independent assessor for HTA
- Has completed HTA training
- Does not have any connection to those being interviewed
- Cannot be the same person who provides info on risk or the procedure
- They must assess whether the requirements have been met
- will interview donor and recipient separately as well as together and produce a report.
When in transplantation does the report not go to the HTA approvals team?
If the donor is a child
If the donor is an adult who lacks capacity
In all cases of pooled or paired
In all altruistic non directed
In cases where HTA have not delegated decision making
In these cases decision is made by HTA panel
What information should living organ donors receive?
- Surgical procedures and medical treatments, long and short term risks
- Changes of transplant being successful, side effects and complications
- Right to withdraw consent at any time
- until anaesthetic in live
- Until time for first incision in deceased - Right to be free of coercion or threat - consent under these circumstances will not be accepted by the independent assessor
- The fact it is an offence to receive reward or payment and penalties involved
- fine and up to 3 years imprisonment - Donors can seek expenses
- Travel costs and loss of earnings
In altruistic non-directed or pooled donors
- ANONYMITY of donor and recipient and CONFIDENTIALITY must be respected
Rules regarding decreased organ donation
- Removal, storage and use of organs from the deceased is governed by the Human Tissue Act 2004
- Consent must first be obtained
- Trained staff should determine if deceased has given consent by checking Organ Donor Register
- If consent established, inform those close to decreased
- If no records, speak to spouse/partner - done by transplant coordinator
- If deceased wishes unknown, but they have nominated representative, they can consent
- Ask for consent from relatives
- A family member CANNOT OVERRULE deceased wishes - no legal right
- Consent is only required from one person in the hierarchy and should be obtained from the highest ranking
- If number 1 does not consent, lower down cannot overrule
- Spouse/partner
- Parent/child
- Brother/sister
- Grandparent/grandchild
- Niece/nephew
- Step mother/father
- Half brother/sister
- Friend
If a decision is not made quick enough for organs to not deteriorate, can take minimum steps necessary to preserve organs under HT Act
May need coroners consent
Use least invasive procedure e.g. cold perfusion
Psychosocial impact of diabetes
Travelling: extra stresses
- Hot weather can affect insulin
- Have to take all insulin supplies with you
- Cost of insurance
- Risk of hypo in unusual settings
Carrying diabetes ID - stigma and labelling
Eating out difficult: choosing food with unknown content
issues with driving - need to inform DVLA if multiple hypoes
- Car insurance CANNOT be increased due to diabetes
Restricted career choice
- Blanket ban on armed forces
- Difficult to manage with shift work
- Subject to individual medical assessment in police, ambulance or fire service
- Embarrassment of hypo in community or work
- Increased sexual dysfunction
- Can alter relationship dynamic
- Difficulty making new relationships esp if sexual dysfunction
- Increased risk in pregnancy
- Increased risks to baby
Often diagnosed in school
- Stigma/bullying
- Disruption to schooling with meds
- Having to inject at school
- Worry of hypos at school
- Reliance on teachers for medication
- issues with compliance
Anxiety/Grief/Depression/Shame/Guilt
TB control of spread in the healthcare setting
- Admit to single room until at last 2 weeks of treatment
- Minimise the number and duration of outpatient clinics
- See patients in less busy areas at less busy times
- Risk assess for multi-drug resistance - if it is then negative pressure room only
- Don’t admit to wards with immunocompromised patients
- Ideally keep at home
- Patients wear surgical mask when leaving the room
Contact tracing in TB
Only screen close contacts Do not routinely trace social contacts Risk assess - Social contacts in high risk groups - School pupils - Hospital in patient in the same bay for > 8 hours - Flights > 8 hours < 3m ago
Inform HPA
Opportunistic case finding in TB
Assess new entrants from high burden countries.
In places of high TB - mobile X-ray e.g. homeless and drug users - can use simple incentives like food and drink
Screen prisoners within 48 hours of arrival
Methods of ensuring adherence to TB meds
Allocate named TB case manager
Health and social care plan and support
Offer directly observed therapy if
- not adhering
- homeless
- drug abuse
- Multidrug resistant
- prison
- at patient request
- to ill to administer
Address fears of stigmatisation Emphasise importance of completing - educate! - Home visits - Education booklet - Random urine tests - Reminder letters - pill counts - Calls/texts as reminders - incentives - Support
Current stance of the UK on organ donation
Opt - in system
A person has to register their consent to donate organs in the event of their deathout-out organ donation system
Presumes consent for organ donation unless a person has registered an objectification in advance.
If an objection has not been registered, family can still be given the opportunity to confirm any unregistered objection as an extra safeguard
Reasons for the opt out system of organ donation
- More organs become available.
- better supply of organs - get organs from those who would donate but didn’t volunteer
- Reduces current pressure on relatives consent when they are grieving.
- Up to 90% support organ donation but number signed up is much lower.
- Still allows those with strong objections to do so
- Reduced wastage of organs
- Every organ has the chance to save a life
Hard opt put organ donation system
- Doctors can remove organs from every adult that dies unless a person has registered to opt out
- Austria
- Singapore: however, they automatically opt out Muslims
Soft opt put organ donation system
- Doctors can remove organs from every adult who dies unless they have opted out or relatives tell the doctors not to take organs
- Belgium it is the relatives responsibility to tell the doctors
- Spain: relatives should be consulted
Reasons against the opt out system of organ donation
May not have heard about opt out - may object and still have organs removed (not respecting patients wishes)
- Creates a pressure to donate - people may feel ashamed of opting out
- Can’t dictate what happens to peoples bodies when they die (autonomy)
- Very sensitive issue and as such should be entirely voluntary
- Costly and complicated to implicate - would need to reach every person
- Would be better to design a program to increase number of donors
- Suggests that bodies belong to state once dead - seen as offensive
- Don’t get consent, just a lack of consent.
What is an audit?
Aims of an audit?
Quality improvement cycle that involves measurement of the effectiveness of healthcare against the agreed and proven standard for high quality and taking action to bring practice in line with these standards to as to improve the quality of care and health outcomes
Aims: • Encourage teamwork • Contractual obligation • Financial incentives • Assess current standards against national standards • Improve the standards of care • Educate and train HCWs
Main challenges posed to an effective audit
- Purpose: many are done as a tick box exercise with little understanding as to why
- Burden of evidence: perceived needs to collect sufficient data from poor sources to justify conclusions
- Time: takes a long time to extract meaningful data from notes and written records
- Organisational inertia: external pressure on clinicians to measure, report and improve often results in resistance to change
- Lack of support: not enough support from superiors and audit departments
- Cultural factors: traditional hierarchies can disempower junior doctors
Define quality improvement
Wider goal than Audit
QI is an umbrella under which audit sits
It is used in examining a clinical process and seeking to improve it. There are circumstances where clinical audit may be appropriate
- Encourages data collection from a resource that can determine if change is needed
- Has a more collaborative working style to investigate problems
Problems with audits
Not useful if there are no national agreed criteria and standards e.g. patient safety, patient experience and performance of a service
Rarely take into account local differences
When should an audit be used?
Used to check clinical care meets defined quality standards and monitor improvements to address shortfalls identified
Most effective for ensuring compliance with specific clinical standards and driving clinical care improvement
Stages of an audit
Stage 1 - identify current standards e.g. from NICE guidelines
Stage 2 - measure current performance e.g. collecting existing information
Stage 3 - compare performance vs set standards
Stage 4 - identify steps to improve performance & make these improvements
Stage 5 - re-evaluate and re-audit
PDSA cycle
Plan
Do
Study
Act
Used to introduce and test potential quality improvements and refine them on a small scale prior to wholesale implementation.
Most effective when a procedure, process or system needs changing or a new procedure, process of system needs introducing.
Tests changes to assess their impact, ensuring new ideas improve quality before implementation on a wider scale.
Making changes can give unexpected results so it is safer to test on a small scale first and allows stakeholders to be involved in proposed changes.
Risk factors for drug addiction
Early aggressive behaviour Lack of parental supervision Substance abuse Drug availability Poverty Care giver who uses drugs Fhx of drug addiction Male Mental health disorder Peer pressure Loneliness, anxiety or depression Child abuse Neglect Poor academic performance ADHD Bullying Deviant peer group Conduct disorder Poor family relationships
Protective factors against drug addiction
Self-control Parental monitoring Academic competence Anti-drug use policies Strong neighbourhood attachment Consistent discipline in childhood
Aetiology of drug addiction
Environmental - risk factors
Genetics: development of addiction can be influenced by genetics
Stages of drug addiction
Initial use
- Motivated by: curiosity, peer pressure, psychodynamic processes
- If drug taken repeatedly - casual drug use
- More frequently using high doses - intensive drug use
- Compulsive drug use = substance has strong motivational properties and appears to govern an individuals behaviour
- Experimental or circumstantial
- Casual drug use
- Intensive drug use
- Compulsive drug use
- Addiction
Theories of drug addiction
Physical dependency model - after repeated exposure, get withdrawal symptoms. They act as negative reinforcement and cause continued drug use
Positive reinforcement model - drug acts a positive reinforce causing a change in behaviour
Reinforcement system in the brain
- Reinforcers are thought to increase the effect of dopamine
- Increased dopamine release
Potential future health promotion strategies for alcohol reduction
Minimum unit pricing
Label alcohol with health warnings
Sale of alcohol in shops restricted to certain times
Higher tax on alcohol
Prohibit alcohol advertising and sponsorship - or limit to purely factual information
Regulartion of alcohol packaging and design
Train all health and social workers on giving alcohol advice
Recommended alcohol units
No more than 14 units per week in men and women
Ideally 2 alcohol free days
The Transtheoretical Model (Stages of Change)
Precontemplation Contemplation Preparation Action Maintenance Relapse
The Transtheoretical Model (Stages of Change) - Precontemplation stage
- User is not considering change
- Is aware of negative consequences
- Is unlikely to take action soon
- Need information linking substance with problems
- Brief intervention: education about negative consequences
Interview approach
- express concern
- agree to disagree about severity of problem
- suggest bringing family member
- explore perception of drug abuse problem
The Transtheoretical Model (Stages of Change) - Contemplation stage
User is aware of some pros and cons but feels ambivalent to change - not yet committed to a change
- Explore feelings of ambivalence
- Seek to increase awareness of continued abuse and benefits of stopping
Interview approach
- Elicit positives and negatives, help tip the decisional balance
- Ask about past abstinence
- Consider trial
- Self-Motivational statements of intent and commitment
The Transtheoretical Model (Stages of Change) - Preparation stage
User has decided to change and begins to plan steps towards recovery
- Needs to work on strengthening commitment
- List options for treatment to choose from
Interview approach
- Clarify goals and strategies
- Acknowledge significance, offer options and advice
- help patient decide on achievable action
- Consider and lower barriers for change - finances, transport
- Have them publicly announce plans for change
The Transtheoretical Model (Stages of Change) - Action stage
User tries new behaviours, not yet stable
First active step towards change
- help executing the plan
- brief interventions can help prevent relapse
Interview approach
- Source of encouragement and support
- Acknowledge negatives and reinforce importance in continuing
- Support realistic view of change using small steps
- Identify high risk situations and develop coping strategies
The Transtheoretical Model (Stages of Change) - Maintenance stage
Established new behaviours on a long term basis
- help with relapse prevention
- Support lifestyle changes
- Help to practice and use coping strategies
- Maintain supportive contact
- Anticipate difficulties and recognise the struggle
The Transtheoretical Model (Stages of Change) - Relapse stage
Recurrence of symptoms and must now cope with consequence and decide what to do next
- Help them re-enter the change cycle
- Commend any willingness to reconsider positive change
- Explore what can be learned from relapse
- Express concern about relapse
- Support patient so recovery seems achievable
Limitations and harms of PSA as screening tool
- May not reduce the change of dying from prostate cancer. Some tumours grow very slowly and are unlikely to threaten life.
OVERDIAGNOSIS AND OVERTREATMENT - Side effects of overtreatment: surgery, radiotherapy (urinary incontinence, bowel control issues, ED, infection)
- May not be useful for those with fast growing as may have mets before detection
- False positives and false negatives
(anxiety) - Most men with raised PSA do not have prostate cancer
- Non specific test as will detect aggressive and slow growing tumours
When is PSA useful
For monitoring for recurrence
When should a PSA be done
If prostate cancer is suspected
A man over 50 can ask for PSA
- GP must explain risks and benefits
- Give any written info
- Answer any questions
When should a PSA not be done
Recent urine infection
Ejaculated in last 48 hours
Exercised heavily in last 48 hours
Had a prostate biopsy in the last 6 weeks
Lung disease associated with asbestos exposure
Which professions increase asbestos exposure?
Mesothelioma
Asbestosis
- Construction workers
- Home remodellers
- Shipyard workers
- Workers who mine, mill or manufacture it
Lung disease associated with silica exposure
Which professions increase silica exposure?
Silicosis
- Coal miners
- Foundry works
- Potters
- Sand blasters
- Tunnel workers
Jobs associated with asthma
- Woodworkers - wood dust
- Spray painter - isocyanates
- Solderer - colophony
- Metal workers - Cobalt, nickel
- Bakers, millers, farmers - Cereal grains
Epidemiology of depression
25% at some point 5% annual 1/4 women, 1/10 men More common in women Increased in Blacks, Asians, refugees Increased in 25-44 and elderly
RFs
- Unemployment
- Lower income
- Debt
- Violence
- Stressful life events
- Inadequate housing
- Poverty
- Smoking
- Lower education
- Genetic FHx
- Pregnancy (post natal)
- Physical illness causing pain
- Dementia
- Other mental health problems
Associations and issues between mental health problems and sensory impairments
- May have unassessed or undiagnosed LD as verbal IQ tests are inaccurate
- Few residential or nursing homes can sign to deaf people
- Limited access to specialist mental health services - postcode lottery
- Difficulties communicating with GPs
- Equal prevalence of mental health problems
In children higher prevalence due to:
- Excess organic problems
- Excess emotional, physiological and behavioural disorders
- Delays to access which increases duration
- Care often poor
- Increased stresses
- Socially isolated
Lack or understanding
Little support available
Methods of preventing AKI
NEWS score to assess those at risk
iodinated contrast agents - IV volume expansion if high risk or acute illness with sodium chloride
Stop ACEi and ARBs if GFR < 40
Advice from pharmacy if high risk
Detection of AKI
RIFLE, AKIN, KDIGO
Rise of creatinine of greater than 26 in 48 hours
50% rise in creatinine within 7 days
Fall in urine output to less than 0.5ml/kg/hr
Risk factors for AKI
Over 65 Heart failure Liver disease CKD Past AKI Diabetes Fluid intake dependent on carer Hypovolaemia Oliguria Haematological malignancy Sepsis Urological obstruction Iodinated contrast agents Nephrotoxic meds: ACEi, ARBs, NSAIDs, aminoglycosides, diuretics Deteriorating NEWS score
Define addiction
Compulsive need to use a habit forming substance
This compulsion is accompanied by an increased tolerance and experience of withdrawal symptoms
Impact of addiction on health
Organ damage Hormone imbalance Cancer Prenatal and fertility issues GI disease HIV/AIDS/hepatitis Depression Anxiety Memory loss Mood swings Paranoia
Impacts of addiction on society
- More work days lost
- Increased number of people claiming benefits and not paying taxes
- Increased criminal activity
- Illegal drugs - funding other types of criminality
- Drain on healthcare resources
- Drain on economy
- High risk of accidents or becoming a victim of crime
- Can destroy communities
Impacts of addiction on the family
- Erratic behaviour, physical/verbal abuse
- Some can be high functioning but most are poor providers
- Financial difficulties
- Stealing from family members
- Unable to care for children - neglect
- Set bad examples to child
- Increased divorce rate
- Change of relationship with friends and family
Impacts of addiction on the individual
Person is obsessed with substance and neglects other areas of their lives
Life is unfulfilling + filled with despair
Increased morbidity/mortality
Worse mental health/increased suicide risk
Poor attendance at work, difficult finding work
Mood swings
Increased probation, arrests, prison time
Increased homelessness
Secretive behaviour
Information that should be given to an obese person
Being overweight and general health risks
Realistic targets for weight loss
Distinguishing between weight loss and maintaining weight loss
Realistic exercise and healthier eating targets
Treatment options
Healthy eating in general
Medical and surgical options
Diet changes advised for obese person
DO NOT
- use restrictive and nutritionally unbalanced diets as they are ineffective in the long term and can be harmful
- FOLLOW FADS
BE
- Flexible
- Encourage diet improvement even if no weight loss
Diet with 600kcal deficit per day.
Can consider 800-1600 kcal per day but less balanced.
Swap unhealthy and high energy foods for healthier choices
5 fruit and veg a day
Wholegrain varieties of starches
Lower sugar milk and dairy - yoghurt, soy
Eat beans, pulses, fish, eggs, meat and other protein
2 portions of fish per week
Plenty of fluid
Define overweight, obese and morbidly obese
Overweight BMI >25
Obese BMI > 30
Morbidly obese BMI > 40
Social implications of obesity
Discrimination Lower wages Lower quality of life Transport difficulties - planes, trains, buses Difficulty buying clothes More likely to commit suicide More likely to divorce Fewer friends Depression and anxiety Body dissatisfaction
Physical implications of obesity
Increased risk of:
- heart disease
- stroke
- diabetes
- hypertension
- high cholesterol
- asthma
- sleep apnoea
- gallstones
- kidney stones
- infertility
- OA
- fatty liver disease
- cancer: leukaemia, breast, colon
Increased morbidity and mortality
life expectancy reduced by more than 9 years
Economic implications of obesity
Lost days of work High employer insurance premiums Lower wages and income Large costs on the health care systems Increased social services having to provide care
Members of the cancer MDT
Surgeon Radiologist Histopathologist Oncologist - clinical and medical Haematologist Palliative care specialist GP Physicians of appropriate speciality Clinical nurse specialist Ward nurses MDT coordinator Admin/managerial
Domains important for MDT functioning
Structure:
- Membership and attendance
- Technology (Availability and use)
- Physical environment of the meeting room
- Preparation for MDTs
- Organisation and admin during the meeting
Clinical decision making:
- Team working
- patient centred care
Team governance:
- Leadership
- Data collection, analysis and audit
Professional development and education of team members
Benefits of an MDT
- Improved clinical decision making
- More coordinated patient care
- Improvement to overall quality of care
- Evidence based treatment decisions
- Increased number of patients being considered for trials
- Improved timeliness of tests and treatments
- Improved survival rates
- Increase proportion of patients staged (cancer)
Epidemiology of obesity
62% of UK adults are overweight or obese
65% men, 58% women
25% of them are obese
- Prevalence is similar among men and women
- More men are overweight
- More women are obese
- Women are more likely to have extremely high BMI values
Causes of obesity - contributing factors
BIOLOGY
- Influence of genetics and ill health:
- Prader-Willi, Hypothyroidism, Cushing’s
ACTIVITY ENVIRONMENT
- Influence of environment on the individuals activity behaviour
- e.g. decision to cycle to work influenced by road safety, cycle shelters, showers
PHYSICAL ACTIVITY
- Type, frequency, intensity
SOCIETAL INFLUENCES
- Impact of media, education, peer pressure, culture
INDIVIDUAL PSYCHOLOGY
- Drive for particular foods
- Consumption patterns
- Physical activity patterns or preferences
FOOD ENVIRONMENT
- Availability and quality of fruit and veg near home
- Demand for convenience
- Lack of perceived time
FOOD CONSUMPTION
- Tendency to graze
- Parental control
Reasons for increasing obesity prevalence
- Frequent large meals
- Food high in refined grains, red meat, unhealthy fats, sugary drinks
- Increased television
- Increased use of cars
- Busier lifestyles
- Longer commutes - snacking
- Increased advertising
- Sleep issues
- Increased stresses and boredom
- Decreased cost of fats and sugars
What is the Health Protection Agency (HPA)
Key organisation in the control of communicable disease
What law covers control of infectious diseases?
Public Health Act 1984 (control of diseases) & 1988 (infectious diseases)
Aims to reduce the spread of communicable disease
- Act on clinical suspicions, do not wait for definitive diagnosis
- Legal requirement to notify Health Protection Agency (HPA)
- Notify Consultant in Communicable Disease Control
Ways to minimise infection spread?
Treat patient
Minimise chances of other getting same infection
- Chemoprophylaxis after meningitis to contacts
Reduce infectiousness of the bug = antibiotics
Contain infectivity
- Isolate in side room
- Exclusion from certain activities e.g. work or school
- Hand washing
- Personal protective equipment
- Managing blood and body fluids adequately
- Education of patients
- Cough etiquette
IMMUNISATION
Powers of the consultant in communicable disease control
- Notification of infectious disease
- Prevents sale of infected articles
- Prevents infected people from using public transport
- Cleaning and disinfection of premises
- Excluding people from work and school
- Offering immunisation
- Compulsory exclusion
- Remove to hospital and detain there
- Obtaining information from households and schools to prevent spread of disease
List notifiable diseases
- Polio
- Acute encephalitis
- Anthrax
- Cholera
- Diphtheria
- Dysentery
- FOOD POISONING
- Malaria
- MEASLES
- MENINGITIS
- MUMPS
- Plague
- Rabies
- RUBELLA
- SCARLET FEVER
- SMALLPOX
- TETANUS
- TB
- Typhoid fever
- VIRAL HEPATITS
- Viral haemorrhagic fever
- WHOOPING COUGH
- YELLOW FEVER
**HIV is not a notifiable disease but practitioners should make sure that any sexual partners have been notified
Define primary prevention
Activities aimed at stopping a disease from developing in the first place
Define secondary prevention
Activities aimed at stopping adverse events once a disease has happened
Define tertiary prevention
Limiting the impact that adverse effects have on health
Primary, secondary and tertiary prevention examples in CHD
Primary
- Smoking cessation in someone without heart disease
- Weight loss in someone without heart disease or diabetes
Secondary
- Antiplatelet therapy post MI
- Statins for those post MI or stroke
Tertiary
- Beta blockers in heart failure
- Cardiac rehabilitation program post MI
What is the prevention paradox?
A preventative measure that brings a large benefit to the community offers little to each participating individual
Most heart disease occurs in people who are not high risk.
It is easy to identify those at high risk
If you improve chances for people at low risk then stands to gain more as a population.
Define risk
Probability that an even occurs in a given time
Determining risk of CHD
Joint British Societies Risk Prediction chart
Uses UK GP data rather than Framingham data
QRISK 2
- Overestimates low risk
- Underestimates high risk
- Does not take into account socioeconomic position and ethnicity
QRISK2 criteria
Age Sex Postcode Smoking Diabetes Angina or MI in first degree relative < 60 CKD stage 4 or 5 AF On BP treatment RA Cholesterol BMI
Diabetes Prevention Program Trial
DPPT
In overweight people with raised fasting glucose
- Allocated to either: intensive lifestyle changes OR standard lifestyle recommendations + metformin OR placebo
- Incidence of diabetes was lower in the intensive lifestyle changes group
- Lifestyle is better than metformin for preventing T2DM
Intensive lifestyle was minimum 150 minutes of exercise + 16 lesson curriculum + 7% weight loss
Risk factors for T2DM with relation to weight
Degree in which patient is overweight
Change in weight
Duration patient is overweight
Increasing BMI
Basic CAMHS structure
Informal Tier Tier 1 Tier 2 Tier 3 Tier 4
CAMHS Tier 1
Professionals
Any tier 1 person can refer to a PRIMARY MENTAL HEALTH WORKER
They are not mental health specialists but have regular contact with children and young people
Offer advice and treatment for less severe problems, promote good mental health, facilitate early identification of problems and refer
- Teaching assistants
- Teachers
- Paediatricians
- GP
- Social worker
- Health visitor
- School worker
- Public health nurses
- Voluntary workers
Role of primary mental health worker
In CAMHS
Bridge between tier 1 and 2
- provides consultation and advice to the professional in tier 1
- Assess the child
- Carry out short term work with the family - up to 4 session
- Co work with referring professions
- Refer onto other agencies .e.g. social service and education and support services
- Refer up tiers 2, 3, 4
CAMHS Tier 2
Everyone that specialises in child mental health
Specialist CAMHS clinicians working in community setting
Offer consultations to support severe or complex needs
- Psychologist
- Nurse
- OT
- Social worker
- Psychiatrist
- Psychologist
- CPNs
- Creative therapists
CAMHS Tier 3
Teams depend on locality and requirements
Very specialist teams
Family therapy LD Attention problems Looked after children Eating disorder Autism Adoption support Paediatric liaison Self-harm Psychosis Bereavement Palliative care
CAMHS Tier 4
Inpatient units For young people with - psychosis - severe eating disorders - severe OCD - severe depression
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
What are health visitors
Qualified nurses with specialist training who work in the community
Steps of an audit
- Select topic
- Review literature
- Set standards
- Design audit
- Collect data
- Analyse data
- Feedback findings
- Change practice
- Set/review standards
- Reaudit
Define relative risk
Also referred to as risk ratio
It is the probability of an event occurring
e.g. developing a disease in an exposed group vs non exposed group
RR = probability when exposed / probability when not exposed
Used in RCTs and cohorts
Define absolute risk
Risk of developing the disease over a period of time
Number of events in a group/ number of people within the group
Define relative risk reduction
Absolute risk in control - (absolute risk in treatment / absolute risk in control)
RRR = 1 - relative risk
Define absolute risk reduction
Absolute risk in the control group - absolute risk in the treatment group
Number needed to treat
1 / absolute risk reduction
Needs to be expressed as a whole number
NNT BENEFIT = round up
NNT HARM = round down
Extending the time period in which the risk is expressed will decrease the number needed to treat
What information is needed in order to assess a number needed to treat?
Needs to have a time period e.g. within 10 years
Look at the nature of the outcome
Decide if looking at something that is getting better or work (NNT benefit or harm)
Define attributable risk
Difference in the rate of a condition between an exposed and unexposed population.
Also called risk difference of risk rate difference.
Incidence in exposed - incidence in unexposed
Define population attributable risk
Reduction in incidence that would be observed if the population were entirely unexposed in comparison to its current exposure pattern.
Strategies to tackle obesity in the community
Increase availability of heathier food in public service venues
Improve availability of healthy food - subsidise
Provide incentives for food retailers to locate healthier products in prime areas
Small portion sizes in public service venues
Limit advertisement of unhealthy goods
Discourage consumption of sweet drinks
Increase support for breastfeeding
Increase school PE requirements
Compulsory PE
Enhance infrastructure to encourage walking and cycling
Improve safety in areas where people could be physically active e.g. schools
Healthy school dinners
Clear food labelling
Increased education - change for life
Weight loss advice
Promote physical activity in the workplace
Raise awareness of complications
Teaching in schools about healthy diets and exercise
National cancer research institute
Started in 2000 with NHS cancer plan
Brings together all the key players in research to identify where research is most needed
Partnership of UK cancer research funders to promote collaboration
Support advancement of areas lacking in research
NHS supported clinical trials
Comprised of 7 government partners and 14 charities
Activities of the national cancer research institute
Maintains database of cancer research in UK
Organising annual NCRI cancer conference
Developing a plan to network UK cancer registries and encourage epidemiological research
Revitalise UK radiotherapy research
Development of the national Cancer Research Network
Setting up a network of experimental cancer medicine centres
Publish reports on key areas
Establish the National Cancer Intelligence Network
National Cancer Research Institute AIMS
Foster research aimed at:
- Better prevention leading to lower cancer risk for the individual
- Earlier diagnosis
- Better, cost effective treatments with more people cured
- Less inequality in outcomes for patients
- Improvements in health and quality of life for people who survive cancer
National Cancer Research Network
Aims to improve speed, quality and integration of research to improve patient care
- Increase funding for trials
- Provides researchers with practical support
- Increases participation in clinical research, raising the number of patients entering trials
- Engages with stakeholders
- Ensures research is translated into benefits for patients,
Screening programs offered in the UK
Adults:
- Diabetic eye disease - Retinography
- Breast cancer - Mammography
- Colorectal cancer - Fecal occult blood
- Cervical cancer - Smear test
- AAA - Ultrasound
Antenatal:
- Down’s, Edwards’, Patau’s syndrome
- Infectious diseases: HepB, HIV, syphilis
- Inherited conditions: sickle cell, thalassaemia, other haemoglobin disorders
- Ultrasound for abnormalities: spina bifida
Neonatal (48 and 72 hours): - Newborn hearing Newborn bloodspot: - Phenylketonuria (PKU) - Congenital hypothyroidism (TSH) - Sickle cell disease - Cystic fibrosis (immunoreactive trypsinogen)
Diabetic retinopathy screening
Everyone over 12 with diabetes receives it annually
During pregnancy - at first antenatal clinic and at 28 weeks
Breast cancer screening
Mammography
Women aged 50-70: 3 yearly
Trail extension: 47-73
Colorectal cancer screening
Faecal occult blood
Every 2 years from 60-74
Cervical screening
Cervical Smear
Every 3 years from 25-50, every 5 years 50-64
Tests for HPV and cell changes
AAA screening
Men aged 65 are offered US scan
If normal, never tested again
If small-medium then regular monitoring
Key concepts of screening
Requires a judgement between balance of helping and harming
Early detection is necessary for screening but in itself does not provide benefit
Population screening is about programmes not tests
Harms of screening
AAA - a person that dies during surgical repair of AAA detected through screening
Down’s - loss of normal foetal following investigation of a high risk screening test
Colorectal cancer - healthy individual who suffers from perforation of bowel during colonoscopy following screening
Patients receiving additional tests due to false positives on screening e.g. biopsy
Lead time bias
If you succeed in early detection of a disease then you increase the time between diagnosis and death - even if treatment is useless
- Care not to count this extra time as benefit
- Need to use number of events prevented rather than survival time.
Healthy screenee effect
Patients who participate in screening often make other health conscious choices.
Different lifestyles between those who take up screening and those who don’t.
Length bias
Screening tends to detect disease which progresses more slowly
The screening detected disease will have better outcomes as they have less aggressive disease
It appears as if the cancers detected by screening have better outcome
Mental Capacity Act 2005
Provides statutory framework to empower vulnerable people who are not able to make their own decisions.
It makes it clear who can make decisions, in which situations and how they should go about this.
It applies to those aged 16 and over.
Principles of the Mental Capacity Act 2005
Assessment of mental capacity is specific for each individual decision at any given time
- Presumption of capacity: every adult has the right to make their own decisions and must be presumed to have capacity unless proven otherwise
- The right for individuals to be supported to make their decisions. People must be given all appropriate help before anyone concludes they cannot make decisions.
- Individuals retain the right to make an unwise decision
- Best interests anything done for or on behalf of people without capacity must be in their best interests
- Least restrictive intervention possible
To have capacity a person must?
To have capacity a person must:
- Be able to understand information provided
- Be able to retain this information
- Be able to weigh up pros and cons
- Be able to communicate this decision
When can restraint be used in those that lack capacity
Restraint is only permitted if it is deemed reasonable to prevent harm
Needs to be proportionate to likelihood and seriousness of harm
Advanced Care Planning
Gives the person the right to make decisions about healthcare treatment in the future for times when they no longer have capacity.
- Replaced advanced directives
- Only over 18s
- Must currently have capacity
- Any treatment can be refused except for those to keep a person comfortable - food, water, warmth, shelter
- Can express which treatments you would like but cannot demand
- It carries the same weight as a person with capacity so best interests does not apply
- Can be verbal unless about life-sustaining treatment which must be written and signed by patient and a witness, plus a statement that it is still to apply if life is at risk
- Becomes invalid if the decision is withdrawn while still has capacity
- Must apply to the specific circumstance in question
Lasting powers of attorney
Can appoint an attorney to act on their behalf if they lose capacity in the future
Lets them make financial, property, health and welfare decisions
Attorney must be over 18
Only comes into force once a person loses capacity
Must be registered with the Office of Public Guardian
Independent Mental Capacity Advocate
Appointed if someone without capacity has no one to speak for them
Makes representations about patients wishes
Can challenge the decision maker
MUST be involved if:
- Serious medical treatment
- Stay of more than 28 days in hospital or 8 weeks in care home
- Change to accommodation
Deprivation of liberty safeguards
Provides legal protection for vulnerable adults who are not detained under Mental Health Act 1983 but are restricted in freedom due to an inability ot consent to care or accept treatment
Anyone over 18 with
- mental disorder or disability of the mind e.g. dementia or profound LD
- Lack of capacity to give informed consent
If a person lacks capacity, must apply to a supervisory body for authorisation of deprivation of liberty
NHS Outcomes Framework
Provides a national overview of NHS performance
Supports the secretary of state in holding
NHS England to account for improving outcomes and acts to aim to encourage a change in health inequalities.
5 domains:
- Preventing people dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping people to recover from periods of ill health or following injury
- Ensuring people have a positive experience of care
- Treating and caring for people in a safe environment and protecting them from avoidable harms
Measuring quality of cancer services
NHS Outcomes framework
- One year survival from all cancers
- 5 year survival from all cancers
- One year survival from breast, lung, colorectal cancers
- 5 year survival from breast, lung, colorectal cancers
- 5 year survival from all cancers in children
Cancer Patient Experience Survey
CCG Outcomes Indicator Set
PROMs
CCG Outcomes Indicator Set for monitor quality of health services - CANCER
Drives local improvement and sets priorities
- Under 75 mortality from cancer
- 1 and 5 year survival from all cancers
- Record of stage of cancer at diagnosis
- Percentage of cancers detected at stage 1 and 2
- Mortality from breast cancer in females
- Patient experience and survivorship
Cancer Patient Experience Survey
CPES
National assessment of patient satisfaction with their cancer treatment.
In 2014 - asked 110,000 patients, 64% response
Positives
- Given enough information
- Offered a range of treatment options
- Treated with respect and dignity
Negatives
- GP and nurses in GP could do more
- Not enough care form health and social services post discharge
Cancer registries
- 4 in the UK
- 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
Bradford Hill Criteria
Criteria for causation - minimal conditions necessary to provide adequate evidence of a causal relationship between incidence and possible consequence
- Strength - larger = more likely to be causal
- Consistency (reproducibility)
- Specificity - causation likely if a very specific population and disease with no other likely explanation
- Temporality - effect after cause
- Biological gradient - greater exposure = greater incidence of effect
- Plausibility
- Coherence - between epidemiological findings and lab findings
- Experiment
- Analogy
Risk factors for chronic liver disease
Alcohol
Obesity
Viral hepatitis
Metabolic syndrome
Healthcare workers
IVDU
Unprotected sex with multiple partners
Working with toxic chemicals
Certain medications
Ways to reduce viral hepatitis
Hep B vaccine
Antenatal testing for Hep B and C
Test in prisons
Needle exchange programs
Free barrier contraception
Limiting additional damage in chronic liver disease
Alcohol cession
Low sodium diet
Healthy diet
Avoid infections - immunise for hepatitis, influenza, pneumonia
Care RE over the counter drugs
Weight loss
Cancer care UK
3 levels of care
- Primary care
- Cancer UNITs for populations of 250,000 Treat common cancers Diagnostic procedures Common surgery Non-complex chemotherapy
- Cancer CENTRES for populations of 1,000,000
Treat rare cancers
Radiotherapy
Complex chemotherapy
Palliative care runs alongside all 3 levels
Cancer networks
Established in 2000
28 cancer networks in the UK
Work in local areas with clinicians, patients, managers to deliver the National Cancer Strategy to improve performance of cancer services
Becomes known as Strategic Clinical Networks from 2013
- Now wider than cancers
- One per region
- Seeks to reduce inequalities in care
Cancer plan 2000
4 aims:
- Save more lives
- Ensure people with cancer get the right professional support and care as well as the best treatments
- Tack inequalities in health
- Build for the future through investment in the cancer workforce: strong research and preparation for a genetic revolution
Incubation period of salmonella
12 – 72 hours:
Eggs
Peaks in LATE SUMMER
Incubation period for E. Coli?
12 – 48 hours:
Food or animal contact
Strains: O157H7, HUS
Incubation period of B Cereus?
1 -6 hours:
Rice
The fastest incubation time except heavy metals.
Incubation of S. Aureus?
2 – 4 hours, a close second.
Skin
What is cryptosporidium?
Protozoa that resides in the GI tract. Resists chlorination with it’s tough oocytes.
Bad one if immunocompromised!
What about Norovirus?
24-hour incubation period
RNA virus that is highly infective and causes D+V.
Most common cause of viral gastroenteritis and plagues semi-closed environments.
What is C. perfringens?
12-24 hour incubation period
The reason you should refrigerate things properly!
Vegetative cells develop (toxic spores) which cause GAS GANGRENE
What is campylobacter?
- The big papa – the most common reported cause of food poisoning.
- Incubation period is 48 - 96 hours (2-4 days)
- GI tract of poultry and uncooked meat.
Summary of food poisoning
Campylobacter:
- 48-96 hours, 2-4 days
- Meat
- Profuse (bloody) diarrhoea , severe abdo pain
- Most common reported cause of food poisoning UK
Salmonella:
- 12-48 hours
- Poultry, eggs
- Diarrhoea, abdo pain
Norovirus:
- 24 hour RNA virus
- Gastroenteritis
Staph Aureus:
- 2-4 hours
- Skin
C. perfringens:
- 12-24 hours
- Cooked meats develop vegetative cells that produce toxic spore which cause gas gangrene
B. cereus:
- 1-6 hours
- Cooked rice
How to investigate food poisoning outbreaks!?
- Preliminary phase: Establish the nature of the outbreak; who, what, where… How!? Make sure potential sources are removed and people are safe. Start making contacts who can help – those affected or people in the right place.
- Data collection and descriptive epidemiology: Gather more data and analyse (who, what, where, etc – use questionnaires (though chance of bias). Take food histories, even though the method is flawed (people forget, people lie etc)
- Investigate the environment
How would you investigate a point source outbreak?
A cohort study (follow those with a known exposure)
How would you investigate a common source outbreak?
Case – control study; have a group of affected and unaffected people.
Look back to figure out where the problem was
What is the public health act?
Allows the exclusion of people from a public place if they have “dubious” hygiene (lol)
1) Inadequate hand washing and personal hygiene
2) Children at nursery – don’t spread the pox
3) Anybody involved in food prep
4) Healthcare workers working with vulnerable people – very young, very old, pregnant women, immunocompromised patients.
What are the principles of UK food law?
1) Protect the health of the people
2) Protect the rights of the people (don’t get ripped off)
3) Protect the practice of fair trade (support our farmers!)
What is the Food Safety Act (1990)
- Defines what food it – substance that we consume, doesn’t necessarily have to be of calorific value (chewing gum counts) and drink counts too.
- Defines who the authorities are and what are their responsibilities are.
What are the offenses under the e Food Safety Act (1990)?
- Selling food that is injurious to health
- False advertising – food has to be at the quality demanded by the user, they can’t be mislead
- Selling food that is unfit for consumption
What should you as a medic do if you suspect an outbreak? And what should be subsequently enforced?
- Report it to the consultant in charge and to the local authority.
- Wash hands, aseptic tekkerz, barrier nursing, use of side rooms, isolate cases, restrict ward visiting hours, lift cases that are 72 hours symptom free, bare below the elbow etc…
What are the aims of clinical guidelines?
1) Improve care of the patient and therefore outcomes
2) Make recommendations for the best available care using best evidence available
3) Help train professionals
4) To set the standards that clinicians can be compared against
5) Help inform patients (they can google things…)
6) Help facilitate communication between patient and doctor (better relationship)
Is there a checklist to assess if a guideline is good or not?
1) Scope and purpose – has the aim of the study been defined? Have targets and goals been set? Has a population been defined?
2) Stakeholder involvement: Have service users and providers been involved? Get their opinion on things!
3) Rigour of development: Has the best evidence available been sought? Have you even bothered to set selection criteria? Well please tell you at least got somebody else to appraise the study and methods? Was it an external review?
4) Clarity of presentation
5) Applicability of the study: Will it have an effect? Will there be barriers to uptake? Can it be done!? Do you even have the resources or man power to put it into practice!?
6) Editorial independence – Did you do the whole study without bias? Were any conflicts in research declared honestly!? No funding bodies played a part?
How do you calculate sensitivity, specificity, PPV, NPV, LR+ and LR-?
- Sensitivity – number of +ve results/number of people who really have the condition
- Specificity – number of -ve results/number of people who DON’T have the condition
- PPV – number of true +ve results/ ALL positives
- NPV – number of true -ve results/ALL negatives
- LR+ - sensitivity/(1-specicifity)
- LR- : (1-sensitivity)/specificity
PPV increases and NPV decreases with PREVALENCE
Why is there currently no PSA screening?
- PPV of a PSA test is only 30%
- Condition isn’t overly understood in the progression and PSA can be raised by confounders
- Test is invasive and may provide false positive
- Treatment can’t guarantee a better outcome – “watchful waiting”
- No research to say whether it would improve survival
What is lead time bias, length bias and selection bias (with regards to screening?
- Lead time bias: survival appears longer, but really isn’t
- Length bias: slow progressing conditions more likely to be detected: apparent increased incidence
- Selection bias: People who opt in for screening are likely to be healthier and less likely to be unhealthy.
What makes up specialist mental health care facilities?
Out-pt. clinics.
Day hospitals: Non-residential units, require pt. to have supportive home environment to return to. Can also be used to slowly discharge pt. back to community.
Assertive outreach teams: Effectively high level CMHTs for challenging pt. (pose real threat of harm & does not want to engage with mental health services).
In-pt. units: Admitted when high risk (Self or others), grossly disturbed behaviour., or period of assessment needed (diagnosis/treatment efficacy) for severe psychiatric disorder.
Early intervention services: Works with young people over the age of 14 (-35) to deal with first episode of psychosis as evidence earlier treatment improves prognosis. Team workers have much smaller case loads than the CMHT so can provide far more intensive input.
Crisis resolution + home team (CRHT): Team that can support you at home during a mental health crisis=When your mental health is ‘at breaking point’, e.g suicidal ideations, mania, psychotic episodes, severe panic attacks.
- Team is available 24/7.
- Act as final arbitrators for inpatient admission.
- Can provide intensive & flexible home support to prevent admission=give short but intensive input.
- Respond to psychiatric emergencies.
Role of community mental health teams (CMHT)?
- Systematic assessment of patients health and social needs
- Formation of agreed plan to address needs
- Allocation of care coordinates to keep in touch with patients
Members of CMHT?
Psychiatrist:
- Prescribe medication
- May be involved in administering psychotherapy
Community psychiatric nurse (CPN):
- Visit patient at home
- See pt. in out-patient departments
- Can help coordinate the care for patients
- Can administer medications and monitor effects
Social worker:
- Allow patients to talk through their needs and consider social care implication
Includes ensuring patient rights under MHA are considered
Occupational therapist (OT):
- Help to improve ADLs
- Identify what patients can’t do, what support they need etc. to allow them to become independent and regain skills
Clinical psychologist:
- Person giving psychotherapies
- Note: counselling can be given by counsellors with less training
Primary mental health worker:
- Assess and sign-post patients
- Can also provide them with short-term therapy (not-trained)
Team manager:
- Usually a senior nurse or social worker
- Don’t see patients themselves
- Are responsible for running team
Examples of never events
Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower or curtain rails
- Falls from poorly restricted windows
- Chest or neck entrapment in bed rails
- Transfusion or transplantation of ABO-incompatible blood components or organs
- Misplaced naso- or oro-gastric tubes
- Scalding of patients
- Unintentional connection of a patient requiring oxygen to an air flowmeter
Health economics definitions
Cost effectiveness analysis: requires all comparisons to have the same outcome
Cost utility analysis: measures all outcomes on one scale a combination of quantity and quality of life
Cost benefit analysis: measures outcomes in money
Cost minimisation analysis: assumes same outcome, measures costs
Cost consequence analysis: measures costs, measures consequences
Discounting: ‘A bird in the hand is worth two in the bush’
Sensitivity analysis: ‘Vary key assumptions and see if it has an impact’
Quality standards and indicators
Quality standards: models of a high quality service -> something to aim for
Indicators: evidence-based indicators of practice quality -> e.g. QoF indicators, incentive scheme for General Practice
