CSI Flashcards
why is influenza more dangerous
it preferentially binds to receptors in the lower respiratory tract
what are the 3 membrane glycoproteins on Influenza A
haemagglutinin (HA), neuraminidase (NA) and Matrix-2 (M2)
Influenza B shares which two glycoproteins with A
HA and NA + two others
does influenza C cause lower respiratory tract complications
only rarely
haemagglutin acts as (2)
an attachment factor and membrane fusion
HA binds to
sialic acid (to enter cell)
HA binding to sialic acid on RBCs causes
haemagglutination
Neuraminidase is a
glycoside hydrolase enzyme
neuraminidas allows the virus to be
released from cells (not stuck to sialic acid)
natural mutation over time and happens continuously, in all viruses is called
antigenic drift
genetic reassortment that yields a phenotypic change in viruses is called
antigenic shift
over time, antigenic shift can lead to (2)
loss of immunity<div>vaccine mismatch</div>
antigenic shift only happens in
influenza A
antigenic shift means that immediately, most people have
no immunity
why does antigenic shift only happen in infleunza A
other types of Influenza are not able to infect other animals (whichis essential for allowing reassortment)
what are the most common cold symptoms (3)
- mild cough/sore throat<div>- sneezing</div><div>- post-nasal drip</div>
what are the most common flu symptoms (4)
- cough<div>- fever</div><div>- fatigue</div><div>- headache</div>
what are common symptoms of COVID (3)
- loss of taste/smell<div>- fever</div><div>- cough</div>
what is the most common cold virus
rhinovirus
rhinovirus interacts with which cell membrane protein?
ICAM-1
coronavirus interacts with which cell membrane protein?
ACE2
“What are Zola’s triggers (5)”
“<ol><li>The occurrence of an interpersonal crisis</li><li>Perceived interference with social or personal relations</li><li>Sanctioning by others</li><li>Perceived interference with vocational or physical activity</li><li>Temporalizing (for example setting a deadline, i.e. ““I’ll go to the doctor if my fever is not gone by Monday””)</li></ol>”
“According to Helman’s folk model of illness, what does the patient want to know from their doctor?”
“<ol><li>What has happened? This includes organising the symptoms and signs into a recognisable pattern, and giving it a name or identity</li><li>Why has it happened? This explains the aetiology or cause of the condition</li><li>Why has it happened to me? This tries to relate the illness to aspects of the patient, such as behaviour, diet, body-build, personality or heredity</li><li>Why now? This concerns the timing of the illness and its’ mode of onset (sudden or slow)</li><li>What would happen to me if nothing were done about it? This considers its’ likely course, outcome, prognosis and dangers</li><li>What should I do about it - or to whom should I turn for further help? This considers strategies for treating the condition, including self-medication, consultation with friends or family, or going to see a doctor</li></ol>”
ICE stands for?
Ideas, Concerns, Expectations
in sickle cell haemoglobin, hydrophilic glutamate 6 is replaced by
hydrophobic valine 6
which form of HbS can polymerise
deoxygenated
what are the main symptons of sickle cell disease (3)
- sickle cell crises<div>- increased infection risk</div><div>- anaemia</div>
how might a patient self-manage a sickle crisis
- painkillers<div>- staying warm, warming pads</div><div>- drinking fluids</div>
how does drinking fluids prevent a sickle crisis
keeps blood thin and flowing well
how does staying warm prevent a sickle cell crisis
keeps peripheral blood vessels open
why are patients with sickle cell prescribed antibiotics
functional splenectomy
what are two medical treatments that can be given in an acute sickle crisis
- hydroxycarbamide<div>- blood transfusion</div>
what might you see on the blood test of someone with sickle cell anaemia (2)
- higher reticulocyte count, and thus increased MCV<div>- low Hb</div>
why are bone crises common in sickle cell anaemia
”- smaller blood vessels so easily ‘clogged’ by sickled erythrocytes”
why might visual loss occur in a patient with sickle cell anaemia?
- blocked blood vessels in the eye<div>- leads to shoddy blood vessel formation to bypass blockage</div><div>- shoddy vessels break causing retinal haemorrhage and in some cases retinal detachment</div>
are patients with sickle cell at higher risk of stroke
yes
why might a person with sickle cell anaemia take vitamin B12 and folate
manage anaemia and rapid RBC turnover
why are target cells found on the blood film of someone with sickle cell anaemia
loss of spleen function so altered RBCs not removed from circulation
ischaemic stroke is caused by
blood clots
why does sickle cell anaemia cause gallstones
buildup of bilirubin from RBC destruction
why might Howell-Jolly bodies be seen on the blood film of a patient with sickle cell anaemia
functional splenectomy
why might cardiac hypertrophy be seen in sickle cell anaemia
need to pump more blood to compensate for anaemia
what kind of anaemia is SCA
normocytic with high reticulocyte count
Which complication associated with sickle cell disease is most associated with significant memory impairment?
stroke
What is the most common central nervous system disorder associated with sickle cell disease?
Depression
what are healthcare associated infections
infections that patients get while receiving treatment for medical or surgical conditions
what is a central line-associated bloodstream infection
a serious HAI that occurs when germs (e.g., bacteria) enter the bloodstream through the central line (a long flexible tube placed in a large vein that empties out near the heart).
what are 5 common HAIs
<ol> <li>Catheter-associated urinary tract infections</li> <li>Surgical site infections</li> <li>Bloodstream infections</li> <li>Pneumonia</li> <li><em>Clostridium difficile</em></li></ol>
what are the three main types of risk factors for HAIs
medical procedures and antibiotic use, organizational factors, and patient characteristics
what can help to reduce rates of HAIs
proper education and training of health care workers
many HAIs are
preventable
the traditional epidemiologic triad model holds that infectious diseases result from
the interaction of agent, host, and environment
The reservoir of an infectious agent is the
habitat in which the agent normally lives, grows, and multiplies
is the reservoir necessarily the source from which an agent is transferred to a host
no; for example the reservoir of <em>Clostridium botulinum</em> is soil, but the source of most botulism infections is improperly canned food containing <em>C. botulinum</em> spores.
Asymptomatic or passive or healthy carriers are
those who never experience symptoms despite being infected
Incubatory carriers are
those who can transmit the agent during the incubation period before clinical illness begins
Reservoirs include (3)
humans, animals, and the environment
Chronic carriers are
those who continue to harbor a pathogen such as hepatitis B virus or<em>Salmonella</em>Typhi, the causative agent of typhoid fever, for months or even years after their initial infection.
Carriers commonly transmit disease because
they do not realize they are infected, and consequently take no special precautions to prevent transmission
Symptomatic persons who are aware of their illness, on the other hand, may be less likely to transmit infection because (3)
they are either too sick to be out and about, take precautions to reduce transmission, or receive treatment that limits the disease
The term <strong>zoonosis</strong> refers to
an infectious disease that is transmissible under natural conditions from vertebrate animals to humans
The portal of exit usually corresponds to
the site where the pathogen is localized
what is direct transmission
an infectious agent is transferred from a reservoir to a susceptible host by <b>direct contact</b> or<b> droplet spread</b>
direct contact occurs through
skin-to-skin contact, kissing, and sexual intercourse, and also contact with soil or vegetation harboring infectious organisms
<strong>Droplet spread</strong> refers to
spray with relatively large, short-range aerosols produced by sneezing, coughing, or even talking
<strong>Indirect transmission</strong> refers to the transfer of an infectious agent from a reservoir to a host by (3)
suspended air particles, inanimate objects (vehicles), or animate intermediaries (vectors).
<strong>Airborne transmission</strong> occurs when
infectious agents are carried by dust or droplet nuclei suspended in air.
droplet nuclei may remain suspended in the air for
long periods of time
<strong>Vehicles</strong> that may indirectly transmit an infectious agent include (4)
food, water, biologic products (blood), and fomites (inanimate objects such as handkerchiefs, bedding, or surgical scalpels).
what is a fomite
inanimate objects such as handkerchiefs, bedding, or surgical scalpels that can spread an infectious agent
<strong>Vectors</strong> such as mosquitoes, fleas, and ticks
carry an infectious agent through purely mechanical means or support growth or changes in the agent.
The portal of entry refers to
the manner in which a pathogen enters a susceptible host
The final link in the chain of infection is
a susceptible host
Susceptibility of a host depends on (3)
genetic or constitutional factors, specific immunity, and nonspecific factors that affect an individual’s ability to resist infection or to limit pathogenicity
public health interventions are aimed at (3)
<ul> <li>Controlling or eliminating agent at source of transmission</li> <li>Protecting portals of entry</li> <li>Increasing host’s defenses</li></ul>
why may high herd immunity levels still lead to outbreaks
in highly immunized populations, the relatively few susceptible persons are often clustered in subgroups defined by socioeconomic or cultural factors. If the pathogen is introduced into one of these subgroups, an outbreak may occur.
what should we consider for a condition
impact on safety, system and resources
“how can we find out a bacteria’s sensitivities?”
“Antibiotic Sensitivity test<div><img></img><br></br></div>”
what are empiric antibiotics
antimicrobials are given to a person before the specific bacterium is known, anticipate likely cause of disease
why might a patient develop diarrhoea after antibiotic therapy
C difficile overgrowth following microbiome damage
what is candour
“<img></img>”
what is empathy
“<img></img>”
what can antibiotic-resistant infections require (3)
extended hospital stays, additional follow-up doctor visits, and costly and toxic alternatives.
name 3 medical advances dependant on antibiotics
organ transplants, cancer therapy, and treatment of chronic diseases like diabetes, asthma, and rheumatoid arthritis
why are rising community antibiotic-resistant infections concerning (3)
put more people at risk, make spread more difficult to identify and contain, and threaten the progress made to protect patients in healthcare.
how should we prescribe antibiotics (4)
Always prescribe the right antibiotic, at the right dose, for the right duration, and at the right time.
what are common side effects of antibiotics (5)
rash, dizziness, nausea, diarrhea, and yeast infection
what does penicillin disrupt
creation of the cell wall
how does penicillin work
triggers lysis by preventing peptidoglycan cell wall creation
what is the active part of penicillin
beta-lactam ring
how is MRSA resistant to penicillin
“encodes alternative PBP which beta-lactams can’t bind to”
why is the NDM1 gene plasmid so dangerous
encodes a beta-lactamase that is effective against almost all known beta lactams
how does co-amoxiclav work
amoxicillin and clavuamic acid which blocks beta-lactamase
what is dementia
a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities
is dementia a normal part of ageing
no
what is the most common form of dementia
“Alzheimer’s disease”
does dementia affect consciousness
no
what does dementia affect (8)
memory,<div>thinking,</div><div>orientation,</div><div>comprehension,</div><div>calculation,</div><div>learning capacity,</div><div>language,</div><div>judgement.</div>
what is the impairment in cognitive function typically accompanied by
deteriortion in emotional control and soical behaviour
what are the three stages of dementia
early, middle, and late
what are three common symptoms of early stage dementia
<li>forgetfulness</li>
<li>losing track of the time </li>
<li>becoming lost in familiar places</li>
what are five common symptoms of middle stage dementia
“<li>becoming forgetful of recent events and people’s names</li><li>becoming lost at home</li><li>having increasing difficulty with communication</li><li>needing help with personal care</li><li>experiencing behaviour changes, including wandering and repeated questioning</li>”
whar are five common symptoms of late stage dementia
<li>becoming unaware of the time and place</li>
<li>having difficulty recognizing relatives and friends</li>
<li>having an increasing need for assisted self-care</li>
<li>having difficulty walking</li>
<li>experiencing behaviour changes that may escalate and include aggression</li>
“what are common forms of dementia other than Alzheimer’s (3)”
vascular dementia,<div><br></br><div>dementia with Lewy bodies (abnormal aggregates of protein that develop inside nerve cells),</div><div><br></br></div><div>frontotemporal dementia (degeneration of the frontal lobe of the brain)</div></div>
what is the estimated proportion of the general population aged 60 and over with dementia at a given time?
5-8%
what are the principal goals for dementia care (5)
<ul><li>early diagnosis in order to promote early and optimal management</li><li>optimizing physical health, cognition, activity and well-being</li><li>identifying and treating accompanying physical illness</li><li>detecting and treating challenging behavioural and psychological symptoms</li><li>providing information and long-term support to carers.</li></ul>
what are known physical risk factors for dementia (7)
- age<div>- lack of exercise</div><div>- smoking</div><div>- alcohol abuse</div><div>- BMI</div><div>- diet</div><div>- BP, cholesterol, BG</div><div><br></br></div>
what are known psychosocial risk factors for dementia (4)
- depression<div>- low educational attainment</div><div>- social isolation</div><div>- cognitive inactivity</div>
what is mild cognitive impairment
- minor problems with cognition<div>- worse than expected for healthy person of same age</div><div>- not severe enough to interfere with daily life (so not dementia)</div>
how many people over 65 have MCI
5-20%
<div>A person with MCI has mild problems with one or more of the following - VALMR (5)</div>
<ul><li>memory - for example, forgetting recent events or repeating the same question</li></ul>
<ul><li>reasoning, planning or problem-solving - for example, struggling with thinking things through</li></ul>
<ul><li>attention - for example, being very easily distracted</li></ul>
<ul><li>language - for example, taking much longer than usual to find the right word for something</li></ul>
<ul><li>visual depth perception - for example, struggling to interpret an object in three dimensions, judge distances or navigate stairs.</li></ul>
In someone with MCI, however, the decline in mental abilities is greater than in
normal ageing
what can cause MCI (7)
”- ‘pre-dementia’<div>- depression</div><div>- anxiety</div><div>- physical illness</div><div>- poor eyesight/hearing</div><div>- vitamin/thyroid deficiency</div><div>- medication side effects</div>”
do people with MCI have an increased risk of developing dementia
yes but not at all guaranteed
how can MCI be treated (5)
- control heart problems, diabetes<div>- prevent stroke</div><div>- stop smoking/drinking</div><div>- exercise and diet</div><div>- mental and social activity</div>
what are the benefits of diagnosing MCI
- identify and support patients at increased risk of dementia
what are four interventions that either prevent occurence or delay onset of dementia/MCI
Physical activity<div>Mediterranean diet</div><div>Not smoking</div><div>Not drinking to excess</div>
what post-diagnostic interventions can be made after a diagnosis of MCI/dementia (4)
Social isolation<div>Cognitive stimulation</div><div>Prompt treatment of infection</div><div>Prompt treatment of depression</div>
what are the three kinds of cognitive intervention
Cognitive Stimulation, Cognitive Training, and Cognitive Rehabilitation
what is cognitive stimulation
Cognitive stimulation comprises involvement in group activities that are designed to increase cognitive and social functioning in a nonspecific manner.
what is cognitive training
Cognitive training is a more specific approach, which teaches theoretically supported strategies and skills to optimize specific cognitive functions.
what is cognitive rehabilitation
Cognitive rehabilitation involves an individualised approach using tailored programs centred on specific activities of daily life. Personally relevant goals are identified, and the therapist, patient and family work together to achieve these goals (e.g., joining a social group)
what is reminsicence therapy
enable or encourage people to think or talk about personally significant eventsthat occurred in the past
what are other potentially helpful interventions for people with dementia/MCI
- music therapy<div>- art therapy</div><div>- improving living environment</div><div>- excercise (as lifestyle change)</div>
what is a MDT
combination of professionals from different clinical disciplines and with specific expertise, that work together to optimise a patient’s care
what is a MDM
meeting between individuals, or representatives of these different groups/specialties, to plan the best care for a patient.
how can we assess memory
cognitive screening test
“what are characteristic features of Alzheimer’s”
- most common type<div>- gradual onset</div>
what are characteristic features of Vascular Dementia
stepwise progression
what are characteristic features of Lewy body dementia
visual hallucinations
what are amyloid plaques
Amyloid precursor protein, which is usually cleaved by alpha-secretase, becomes aberrantly cleaved by beta and gamma secretases. This results in a relative surplus of amyloid-beta (Aβ), the final product in this enzymatic pathway. Aβ peptides aggregate into oligomers and fibrils with beta-sheet pairing and ultimately become deposited in diffuse, insoluble senile plaques
what are neurofibrillary tangles
However, when Tau is hyper-phosphorylated, it oligomerises and aggregates into filamentous neuro-fibrillary tangles (NFTs)
“many drug treatments for Alzheimer’s disease focus on”
replacing acetylcholine lost via death of neurones in the nucleus basalis of Meynert
“what are four cerebral features of Alzheimer’s”
(1) amyloid plaques,<div>(2) neurofibrillary tangles,</div><div>(3) synaptic deterioration and neuronal death</div><div>(4) cerebro-cortical atrophy.</div>
“name 3 regions associated with the limbic system implicated in Alzheimer’s”
- cingulate gyrus<div>- hippocampus</div><div>- thalamus</div>
name 4 people who might be part of an MDT for a MCI patient
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when is the mental health act used instead of the mental capaciy act
“<img></img>”
give five examples of people who may lack capacity
“<img></img>”
does lacking the capacity to make a specific decision mean that you lack capacity to make any decision
“no<div><img></img><br></br></div>”
when should we assume someone does not have the capacity to make a decision
when this is proven
can you have capacity to make an unwise decision
yes
decisions made for people lacking capacity must
be in their best interests and least restrictive of their basic rights and freedoms
people should be provided with
an independant advocate
what test of capacity does the MCA set up
2 stage:<div><div>1) Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use? </div><div><br></br></div> <div>2) Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time – someone may lack capacity at one point in time, but may be able to make the same decision at a later point in time.</div></div>
“a person is unable to make a decision if they can’t”
“<img></img>”
“Before deciding a person lacks capacity, it’s important to”
take steps to enable them to try to make the decision themselves
how can we take steps to enable them to try to make the decision themselves?
“<img></img>”
“according to the MCA, how do we decide what’s in a patient’s best interests”
“<img></img>”
“who else should we consult for views about a patient’s best interests”
“<img></img>”
what should we try to find beforemaking a decision or act on behalf of someone who lacks capacity
the least restrictive alternative
Where it appears a deprivation of liberty might happen, the provider of care (usually a hospital or a care home) has to
apply to their local authority
the local authority will grant legal authorisation
if the deprivation of liberty is in the best interests of the individual concerned
what is an advance statement
“a written statement that sets down a person’s preferences, wishes, beliefs and values regarding their future care. It’s not legally binding.”
what might an advance statement contain
“<img></img>”
what is an advance decision
legally binding decision that allows someone aged 18 or over, while still capable, to refuse specified medical treatment for a time in the future when they may lack capacity to consent to or refuse that treatment.
an advance decision must
be valid and applicable to current circumstances.
<div>If the advance decision refuses life-sustaining treatment, it must</div>
<ul><li>be in writing, signed and witnessed</li><li>state clearly that the decision applies even if life is at risk</li></ul>
what does a lasting power of attorney do
enable another person to make decisions about your health and welfare, or decisions about your property and financial affair
<div>When acting under an LPA, an attorney (the appointed person) must</div>
“<ul><li>make sure the MCA’s statutory principles are followed</li><li>check whether the person has the capacity to make that particular decision for themselves – if they do, a personal welfare LPA can’t be used and the person must make the decision</li></ul>”
In addition to a LPA the Court of Protection will be able to
appoint deputies who can also take decisions on health and welfare and financial matters if the person concerned lacks the capacity to make a decision.
what is the role of the court of protection
“The <a>Court of Protection</a> oversees the operation of the Mental Capacity Act and deals with all issues, including financial and serious healthcare matters, concerning people who lack the mental capacity to make their own decisions.”
“what are 7 typical early symptoms of Alzheimer’s (MCMCMRL)”
<li><b>M</b>emory problems like regularly forgetting recent events, names and faces.</li>
<li>Becoming increasingly <b>R</b>epetitive, e.g. repeating questions after a very short interval or repeating behaviours and routines.</li>
<li>Regularly <b>M</b>isplacing items or putting them in odd places.</li>
<li><b>C</b>onfusion about the date or time of day.</li>
<li>People may be unsure of their whereabouts or get <b>L</b>ost, particularly in unfamiliar places.</li>
<li>Problems <b>C</b>ommunicating or finding the right words.</li>
<li>Some people become low in <b>M</b>ood, anxious or irritable. Others may lose self-confidence or show less interest in what’s happening around them</li>
“what are serious symptoms of late Alzheimer’s (not just early ones getting worse)”
<li>People may have problems walking, be unsteady on their feet, find swallowing food more difficult or have seizures.</li>
<li>People may experience hallucinations, where they see or hear things that are not there. Others may believe things to be true that haven’t actually happened, known as ‘delusions’.</li>
what are specific symptoms of vascular dementia (4) SPMS
<ul> <li>Slower thinking - taking more time to process information and to form thoughts and sentences.</li> <li>Personality changes – people may become low in mood, more emotional or lose interest in what’s happening around them.</li> <li>Movement problems - difficulty walking or changes in the way a person walks.</li> <li>Stability – unsteadiness and falls.</li></ul>
What are specific symptoms to dementia with Lewy Bodies (SMASH U)
<ul> <li>Changes in <b>A</b>lertness and attention, and periods of confusion, that may be unpredictable and change from hour-to-hour or day-to-day.</li> <li><b>M</b>ovement problems - Parkinson’s-type symptoms such as slower movements, stiffness in the arms and legs, and shaking or trembling.</li> <li><b>U</b>nsteadiness and falls.</li> <li>Visual <b>H</b>allucinations – Seeing things that are not really there, e.g. people or animals. These often happen repeatedly and are realistic and well-formed.</li> <li><b>S</b>leep disturbances - Vivid dreams, shouting out or moving while sleeping which can disrupt sleep, and may cause injury.</li> <li>Sense of <b>S</b>mell – Problems detecting smells.</li></ul>
what are 3 types of frontotemporal dementia
behavioural variant frontotemporal dementia<div>semantic dementia<br></br></div><div>progressive non-fluent aphasia<br></br></div>
In behavioural variant frontotemporal dementia, the parts of the frontal lobe that control what may be most affected
social behaviour
In semantic dementia, the parts of the temporal lobe that support what are most affected.
understanding of language and factual knowledge
In progressive non-fluent aphasia, the parts of the frontal lobe that control what are most affected.
speech
what are specific symptoms of frontotemporal dementa (MAILO)
<li><b>I</b>nappropriate behaviour - this might include making inappropriate jokes or showing a lack of tact. Humour or sexual behaviour may change. Some people become impulsive or easily distracted.</li>
<li><b>O</b>bsessions – people might develop unusual beliefs, interests or obsessions.</li>
<li><b>A</b>wareness - do not realise there are changes in their personality or behaviour.<br></br></li>
<li><b>L</b>anguage - decline in language abilities. This might include difficulty speaking or understanding the meaning of words. People may repeat words and phrases or forget what words mean.<br></br></li>
<li><b>M</b>ovement problems - around one in every eight people with behavioural variant FTD also develops movement problems of motor neurone disease. This can include stiff or twitching muscles, muscle weakness and difficulty swallowing.<br></br></li>
what is pre-diabetes
your blood sugars are higher than usual, but not high enough for you to be diagnosed with type 2 diabetes. It also means that you are at high risk of developing type 2 diabetes.
what are other names for pre-diabetes
<ul> <li>borderline diabetes</li> <li>Impaired Fasting Glucose (IFG)</li> <li>Impaired Glucose Tolerance (IGT)</li> <li>Impaired Glucose Regulation (IGR)</li> <li>Non-diabetic hyperglycaemia</li></ul>
“what is the target range HbA1C if you’re at risk of developing T2DM”
below 42mmol/mol
does pre-diabetes mean you will get T2DM
No, but you need ot act to avoid it
what are symptoms of pre-diabetes
“Prediabetes doesn’t have any symptoms. If you start to have any of the <a>symptoms of type 2 diabetes</a> it means you have probably already developed it.”
how many people are at increased risk of T2DM in the UK
12.3 million
how many cases of T2DM can be prevented
3 in 5
what can significantly reduce your risk of T2DM
losing 5% of your body weight
how can T2DM be prevented
- manage weight<div>- healthy diet</div><div>- be more active</div>
what kind of diet increases your risk of T2DM
“ifyour diet is made up of food and drinks withhighfat, high GI (short for <a>glycaemic index</a>) and lowfibre”
what kinds of diet have been linked with a decreased risk of T2DM
<ul> <li>Mediterranean diet</li> <li>Dietary Approaches to Stop Hypertension (DASH) diet</li> <li>vegetarian and vegan diets</li> <li>the Nordicdiet</li> <li>moderately cutting down on carbohydrates.</li></ul>
what is a sedentary lifestyle
spend a lot of time sitting down
do you need to join a gym to become more active
no, you could make small changes so that you are being more active every day. Think about taking phone calls standing up, using stairs instead of the lift, and going for a walk on your lunch break
what is the NHS diabetes prevention programme
The NHS Diabetes Prevention Programme (NHS DPP) is a joint commitment from NHS England, Public Health England and Diabetes UK, to deliver at scale, evidence based behavioural interventions for individuals identified as being at high risk of developing Type 2 diabetes
diabetes currently accounts for what proportion of the NHS budget
10%
what are the long-term aims of the NHS DPP
To reduce the incidence of Type 2 diabetes;<div>•To reduce the incidence of complications associated with diabetes - heart, stroke, kidney, eye and foot problems related to diabetes; and</div><div>•Over the longer term, to reduce health inequalities associated with incidence of diabetes</div>
why might the incidence of diabetes increase when the NHS DPP is first implemented
In the short-term we recognise that a stronger focus on identifying people who are at risk of diabetes is likely to increase incidence of diabetes as more undiagnosed cases are uncovered.
what are the three core goals of the NHS DPP
achieving a healthy weight<div>•achievement of dietary recommendations</div><div>•achievement of CMO physical activity recommendations</div>
what does the NHS DPP programme consist of
at least 13 sessions, with at least 16 hours face to face contact time, spread across a minimum of 9 months, with each session lasting between 1 and 2 hours. People will be supported to set and achieve goals and make positive changes to their lifestyle in order to reduce their risk of developing Type 2 diabetes. Sessions will be delivered predominantly in face to face groups
who is eligible for the NHS DPP programme
Individuals eligible for inclusion have ‘non-diabetic hyperglycaemia’ (NDH), defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used. Only individuals aged 18 years or over are eligible for the intervention
what are the referral routes into the NHS DPP programme
•Those who have already been identified as having an appropriately elevated risk level (HbA1c or FPG) in the past and who have been included on a register of patients with high HbA1c or FPG;<div><br></br></div><div> •The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk;</div><div><br></br></div><div>and •Those who are identified with non-diabetic hyperglycemia through opportunistic assessment as part of routine clinical care.</div>
in T2DM, what contributes to progressive failure in the function of β-cells
β-cell resistance to the incretin ‘glucagon-like peptide 1’ (GLP1)
in T2DM, what contributes to the excessive glucose production by the liver
increased glucagon levels and enhanced hepatic sensitivity to glucagon
Insulin resistance in adipocytes results in
accelerated lipolysis and increased plasma free fatty acid (FFA) levels, both of which aggravate the insulin resistance in muscle and the liver and contribute to β-cell failure
In T2DM, what in the kidney contributes to the maintenance of hyperglycaemia
Increased renal glucose reabsorption by the sodium/glucose co-transporter 2 (SGLT2) and the increased threshold for glucose spillage in the urine
what contributes to weight gain in T2DM
Resistance to the appetite-suppressive effects of a number of hormones, as well as low brain dopamine and increased brain serotonin levels, which exacerbates the underlying resistance.
What two other factors cause hyperglycaemia in T2DM
- inflammation<div>- vascular insulin resistance</div>
what are symptoms of T2DM
<ul><li>peeing more than usual, particularly at night</li><li>feeling thirsty all the time</li><li>feeling very tired</li><li>losing weight without trying to</li><li>itching around your penis or vagina, or repeatedly getting thrush</li><li>cuts or wounds taking longer to heal</li><li>blurred vision</li></ul>
what are 4 risk factors for T2DM
<ul><li>are over 40 (or 25 for south Asian people)</li><li>have a close relative with diabetes (such as a parent, brother or sister)</li><li>are overweight or obese</li><li>are of Asian, African-Caribbean or black African origin (even if you were born in the UK)</li></ul>
Impaired insulin secretion in T2DM is caused by pancreatic β-cell dysfunctioning owing to (3)
lipotoxicity, glucotoxicity and resistance toincretins (intestinal hormones that stimulate insulinsecretion).
Causes of the insulin resistance include
genetic abnormalities<div><br></br><div>ectopic lipid accumulation</div><div><br></br></div><div>mitochondrialdysfunction</div><div><br></br></div><div>inflammation</div><div><br></br></div><div>endoplasmicreticulum stress</div></div>
What does metformin do
target hepatic glucose production
what is the single most important risk factor for T2DM
BMI >25
Screening for T2DM is recommended for adults who are (3)
≥45 years of age, obese and/or havea family history, especially since randomizedcontrolled clinical trials have shown that intensivelifestyle interventions, sometimes combined withmedication,are effective indelaying andeven preventingT2DM.
what occurs when insulin binds to an insulin receptor on a myocyte
2ndary messenger cascade causes GLUT4-containing vesicles to fuse with the cell membrane and allow glucose into the muscle cell
“what is the ““vicious cycle”” in T2DM”
“<img></img>”
in impaired fasting glucose what is higher than normal
“fasting glucose but nothing else<div><img></img><br></br></div>”
in impaired glucose tolerance what is higher than normal
“post-prandial glucose - NOT random glucose but fasting glucose may be high<div><img></img><br></br></div>”
in diabetes what is higher than normal
“all of fasting, post-prandial, and random glucose<div><img></img><br></br></div>”
what are advantages of the HbA1C test
- cheap<div>- easily avaliable</div><div>- no need to fast</div>
what are disadvantages of the HbA1C test
- average over past 3 months<div>- not suitable in patients with anaemia or haemoglobinopathies</div>
how many people in the UK have diabetes (including undiagnosed)
1 in 16
what is metabolic syndrome
“<img></img>”
what is the EAST framework for behavioural change
“<img></img>”
how many adults over 65 who live at home will have at least one fall a year?
1 in 3
how many adults over 65 who live at home will have more frequent falls?
1 in 6
do most falls result in serious injury
no
what can happen after a fall
“there’s always a risk that a fall could lead to broken bones,and it can causethe person to lose confidence, become withdrawn, and feelas ifthey have lost their independence.”
“what should you do if you have a fall but aren’t hurt (6)”
”- keep calm and don’t get up quickly<div>- roll onto your hands and knees</div><div>- look for a stable piece of furniture</div><div>- hold onto the furniture with both hands to support yourself</div><div>- when you feel ready, slowly get up</div><div>- sit down and rest for awhile</div>”
what should you do if you fall and are unable to get up
”- try to get someone’s attention by calling out for help, banging on the wall or floor, or using your<a>aid call button</a> (if you have one)<div><br></br><div>- if possible, crawl to a telephone and dial 999 to ask for an ambulance</div></div><div><br></br></div><div>- try to reach something warm, such as a blanket or dressing gown, to put over you, particularly your legs and feet</div><div><br></br></div> <div>- stay as comfortable as possible and try to change your position at least once every half an hour or so</div>”
why are older people more likely to fall (3)
“<ul> <li>balance problems and muscle weakness </li> <li><a>poor vision</a></li> <li>a long-term health condition, such as <a>heart disease</a>,<a>dementia</a> or <a>low blood pressure (hypotension)</a>, which can lead to <a>dizziness</a> and a brief loss of consciousness</li></ul>”
what can make a fall more likely
<ul> <li>floors are wet, such as inthe bathroom, or recently polished </li> <li>the lighting in the roomis dim </li> <li>rugs or carpets are not properly secured </li> <li>the person reaches for storage areas, such as acupboard, or is going downstairs </li> <li>the person is rushing to get to the toilet during the day or at night</li><li>falling from a ladder while carrying out home maintenance work.</li></ul>
what health condition can make falls especially dangerous in the elderly
osteoporosis
what raises your risk of osteoporosis
- smoking<div>- excessive alcohol drinking</div><div>- steroids</div><div>- family history of hip fractures</div><div>- post-menopausal</div>
what are simple measures to prevent falls at home (5)
<ul> <li>using non-slip mats in the bathroom </li> <li>mopping up spills to prevent wet, slipperyfloors</li> <li>ensuring all rooms, passages and staircases are well lit</li> <li>removing clutter</li> <li>getting help lifting or moving items that are heavy or difficult to lift</li></ul>
“what can your GP do if you’re at risk of falls”
- check your balance<div>- medications review</div><div>- sight test</div><div>- ECG and BP test</div><div>- request a home hazards assessment</div><div>- excercises to improve strength and balance</div>
what is it called whena healthcare professional visits your home to identify potential hazards and give advice
home hazard assessment
what is a hip fracture
<strong>bony injury of the proximal femur</strong> typically occurring in the elderly
how much do hip fractures cost the NHS and social care per year
£1bn
what is the mean age of a hip fracture patient
80
how much more common are hip fractures in women
x4
what are the 3 sources of blood for the femoral head
- retinacular vessels<div>- foveal artery</div><div>- metaphyseal vessels</div>
what is the main blood supply to the femoral head
“retinacular vessels, supplied by <strong>medial and lateral circumflex</strong><div><strong>vessels</strong></div><div><img></img><strong><br></br></strong></div>”
“<img></img><div>1 shows the</div>”
retinacular vessels
“<img></img><div>2 shows the</div>”
foveal artery
“<img></img><div>3 shows the</div>”
metaphyseal vessels
how may hip fractures be classified relative to the inter-trochantic line
<ul> <li>Above = <strong>intra-capsular</strong></li> <li>Below = <strong>extra-capsular</strong></li></ul>
a fracture above the inter-trochantic line is
intra-capsular
a fracture below the inter-trochantic line is
extra-capsular
“what is Garden’s classification of intra-capsular fractures”
<ul> <li><strong>Type I</strong> - Incomplete, impacted in valgus</li> <li><strong>Type II</strong> - Complete, undisplaced</li> <li><strong>Type III</strong> - Complete, partially displaced</li> <li><strong>Type IV</strong> - Complete, completely displaced</li></ul>
what are risk factors of hip fractures (7)
“<ul> <li><strong>Increasing age</strong></li> <li><a><strong>Osteoporosis</strong></a></li> <li><strong>Low muscle mass</strong></li> <li><strong>Steroids</strong></li> <li><strong>Smoking</strong></li> <li><strong>Excess alcohol intake</strong></li> <li><strong>Metastatic spread of cancer to bone</strong></li></ul>”
what normally causes hip fractures in the elderly
falls
what are mechanisms of hip fractures
- direct falls<div>- twisting</div>
what are bones at risk of hip fracture usually
<strong>osteopaenic</strong> (reduced bone density) and also <strong>deficient </strong><strong>in elastic</strong><strong> reserve</strong> (i.e. they are very brittle).
what causes hip fractures in younger patients
- major trauma<div>- gait disturbance (eg MS)</div><div>- medications (eg prolonger corticosteroid use)</div>
how are hip fractures diagnosed
<strong>Hip fractures are diagnosed radiologically</strong>, but may be suspected clinically.
is it normal for hip fractures to occur with no precipitating trauma
no
what 3 things is it important to elucidate in a fracture history
<strong>why an individual may have fallen</strong><div><br></br></div><div>whether the fall was mechanical in nature (e.g. slipped on a wet floor)</div><div><br></br></div><div>if the event was precipitated (e.g. MI, stroke, chest infection, UTI etc.)</div>
what are symptoms of hip fracture
<ul> <li><strong>Hip / knee pain</strong></li> <li><strong>Inability to bear weight</strong></li> <li><strong>Limited range of motion</strong></li></ul>
what are signs of hip fracture
<ul> <li><strong>Bony tenderness over affected hip</strong></li> <li><strong>Shortened / externally rotated leg (only present if significant displacement)</strong></li></ul>
what are the typical series of images taken in a hip fracture X ray
AP pelvis, AP view of the affected hip and lateral view of the affected hip
“what is Shenton’s line”
“an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth<div><img></img><br></br></div>”
what is initial management of a hip fracture
<strong>analgesia, routine investigations and pre-operative work-up</strong>
what are routine hip fracture investigations
- routine bloods<div>- 2 group and save</div><div>- chest x ray</div><div>- cognitive status</div><div>- catheterisation</div><div>- urine dipstick and midstream urine if relevant</div>
should NSAIDs be given to hip fracture patients
“it’s discouraged”
what analgesia should be given to a hip fracture patient initially
Paracetamol and opiod analgesia should be prescribed with reference to the patients weight, renal function and age.In the absence of contraindications a fascia iliaca block should be offered.
why may regular medication need to be adjusted following hip fracture
may have acute kidney injury
what medications should be held following hip fracture
In general anticoagulants and antiplatelets are held - however context is key! If a patient has had a recent CABG or PCIfor example discussion with cardiology / cardiothoracic surgery is warranted. Where reversal of anticoagulation or coagulopathy is needed discuss with haematology.
how are most hip fractures treated
surgically
what are NICE guidelines on hip surgery for fractures
<strong>NICE guidelines</strong> recommend surgery to be performed on the day of, or the day after, admission. The aim is to allow patients to fully weight bear (without restriction) in the immediate postoperative period.<div><br></br></div><div>The evidence shows without surgery, patients remain bedbound with high risk of blood clots, chest infections and other complications. Surgical fixation on the other hand allows early mobilisation (same-day or next day) and rehabilitation.</div>
what are outcomes like in hip fracture patients who do not undergo surgery
poor
how are m<strong>inimally or non-displaced intracapsular fractures</strong> (e.g. Gardens I/II) treated
These are frequentlytreated with cannulated hip screws (often 2 or 3).
how are<strong>Displaced intra-capsular fractures </strong>(e.g. Gardens III/IV)treated
<div>These tend to be managed either with a total hip replacement(THR)or a hemi-arthoplasty.</div>
<div>NICE advise that THR is offered to patients who:</div>
<ul> <li>Are able to walk independently out of doors with no more than the use of a stick<em><strong>and</strong></em></li> <li>Are not cognitively impaired<strong><em>and</em></strong></li> <li>Are medically fit for anaesthesia and the procedure</li></ul>
how are intertrochantic fractures managed
These may be managed witha dynamic hip screw (DHS) or intra-medullary (IM) nail. DHSare unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.
how are<h3><strong>Subtrochanteric</strong><strong>fractures</strong></h3>managed
These tend to be managed with anintra-medullary (IM) nail.
Post-operatively PT/OT are key<strong>due to</strong>
<strong>helping patients mobilise and get home safely</strong>
what should be screened for post-hip-op
- delirium<div>- chest infection</div><div>- uti</div><div>- op site haematomas/infections (rarer)</div><div>-Significant complications like peri-operative cardiac events and DVT/PE</div>
how can physio help a patient post-hip-op
<div>Patients should be encouraged to mobilise the day after surgery. Early mobilisation helps reduce the risk of blood clots, chest infections and deconditioning. Patients should have daily physiotherapy as an inpatient and a plan for community support at discharge.</div>
<div>Patients home situation should be reviewed and a re-ablement package instituted as needed to (ideally) return the patient to their home or care home.</div>
what is delirium?
a worsening or change in a person’s mental state that happens suddenly, over one to two days. The person may become confused, or be more confused than usual. Or they may become sleepy and drowsy.
delirium is often
the first sign someone is becoming unwell
what are symptoms of delirium
<ul> <li>be easily distracted</li> <li>be less aware of where they are or what time it is (disorientation)</li> <li>suddenly not be able to do something as well as normal (for example, walking or eating)</li> <li>be unable to speak clearly or follow a conversation</li> <li>have sudden swings in mood</li> <li>have hallucinations – seeing or hearing things, often frightening, that aren’t really there</li> <li>have delusions or become paranoid – strongly believing things that are not true, for example that others are trying to physically harm them or have poisoned their food or drinks.</li></ul>
who is often best placed to recognise delirium?
Family, friends and carers – including professional carers – are often best placed to recognise and describe changes because they know the person best. A person with delirium may be unaware of the changes and will often be unable to describe them.
what are the three types of delirium
hyperactive, hypoactive and mixed
do symptoms of delirium stay constant all day
no, they often fluctuate
what are symptoms of hyperactive delirium
<ul> <li>seem restless</li> <li>be agitated (for example, with more walking about or pacing)</li> <li>resist personal care or respond aggressively to it</li> <li>seem unusually vigilant.</li></ul>
what are symptoms of hypoactive delirium
<ul> <li>withdrawn, feeling lethargic and tired</li> <li>drowsy</li> <li>unusually sleepy</li> <li>unable to stay focused when they’re awake</li><li>stopping eating</li><li>more time in bed</li></ul>
what is mixed delirium
symptoms of hyperactive delirium at times and symptoms of hypoactive delirium at other times. They will switch between these symptoms over the day or from one day to the next
is delirium the same as dementia
no, but similar symptoms
what are important differences between delirium and dementia
”- delirium starts suddenly<div>- delirium’s symptoms vary over the day</div>”
which kind of dementia mimicks delirium
Dementia with Lewy bodies.<div><br></br></div><div>This type of dementia has many of the same symptoms as delirium (including visual hallucinations) and they can vary a lot over the day.</div>
what can be used to test for delirium
4AT test
what is the 4AT test
<ul> <li><strong>a</strong>lertness – whether the person is drowsy or agitated</li> <li><strong>a</strong>wareness – for example, of the current year and where they are</li> <li><strong>a</strong>ttention – for example, how well the person is able to name the months of the year backwards from December</li> <li><strong>a</strong>cute change or fluctuating course – whether symptoms started suddenly or are now coming and going.</li></ul>
what can cause delirium
“<ul> <li><img></img><br></br></li><li>pain</li> <li>infection</li> <li>poor nutrition</li> <li>constipation (not pooing) or urinary retention (not peeing)</li> <li>dehydration</li> <li>low levels of blood oxygen</li> <li>a change in medication</li> <li>abnormal metabolism (for example, low salt or blood sugar levels)</li> <li>an unfamiliar or disorientating environment.</li></ul>”
who tends to get delirium
older people in hospital
what factors put people at higher risk of delirium
<ul> <li>dementia – this is the biggest single risk factor for delirium</li> <li>aged over 65</li> <li>frailty</li> <li>multiple medical conditions</li> <li>poor hearing or vision</li> <li>taking multiple medications (for example, antipsychotics, benzodiazepines and certain antidepressants)</li> <li>having already had delirium in the past.</li></ul>
how is delirium treated
- address medical problem(s)<div>- review medications</div><div>- regular eating and drinking</div><div>- good nursing care</div>
how can you help someone with delirium
<ul> <li>talking calmly to the person in short clear sentences, reassuring them as to where they are and who you are</li> <li>supporting the person with familiar objects from home, such as photographs</li> <li>making sure that any hearing aids and glasses are clean and working and that the person is wearing them</li> <li>setting up a 24-hour clock and calendar that the person can see clearly</li> <li>helping the person develop a good sleep routine, including reducing noise and dimming lights at night</li> <li>reassuring the person if they have delusions</li> <li>supporting the person to be active – to sit up or to get out of bed – as soon as they safely can</li> <li>helping the person to eat and drink regularly</li> <li>not moving the person unnecessarily – either within and between hospital wards, or into hospital if delirium is being managed at home.</li></ul>
when should drugs be considered to treat delirium
only if the person’s behaviour (for example, severe agitation in hyperactive delirium) poses a risk of harm to themselves or others, or if hallucinations or delusions are causing the person severe distress
what drugs can be given to treat delirium
low dose of a sedative or an antipsychotic for a few days
what can happen after an episode of delirium
-A person may have distressing memories of delirium, sometimes linked to feelings of fear or anxiety, for months afterward<div><br></br></div><div>-Delirium is linked to a faster worsening of a person’s mental abilities and function.</div><div><br></br></div><div>-In some cases a person will not have a diagnosis of dementia when they go into hospital, but after having delirium their symptoms will get worse and they will later be diagnosed with dementia. In these cases the delirium seems to have ‘uncovered’ the person’s dementia.</div>
“what kind of forces count as ““low energy”” trauma”
equivalent to a fall from standing height or less
what is an osteoporotic fracture
a fragility fracture which has occurred as a consequence of osteoporosis.
what is a fragility fracture
“fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low-energy’) trauma”
what are risk factors for fragility fractures
<li>Advancing age.</li>
<li>Other conditions affecting bone strength, such as acromegaly or osteogenesis imperfecta.</li>
<li>Predisposition to falls due to loss of balance or poor muscle strength</li>
<li>osteoporosis</li>
what are the most common sites for fragility fractures
vertebrae, hip (proximal femur) and wrist (distal radius). Other sites affected include the pelvis, ribs, arm and shoulder
what fragility fractures may go unnoticed
vertebral compression fractures may go unrecognised as a cause of worsening back pain. Up to two thirds of these vertebral fractures are said to be unrecognised at the time of occurrence
what can compression fractures cause
<ul><li>Pain and morbidity associated with high doses of analgesia.</li><li>Loss of height.</li><li>Difficulty breathing.</li><li>Loss of mobility.</li><li>Gastrointestinal symptoms.</li><li>Difficulty sleeping.</li><li>Symptoms of depression.</li></ul>
what should be considered after all fragility fractures
DXA scan of the lumbar spine and X-rays of the spine
what are first line treatments to improve BMD
- cholecalciferol and calcium supplements<div>- bisphosphonates (alendronic acid)</div>
who should be risk assessed for fragility fractures
<li>Those with a history of fragility fracture. Some guidelines suggest this should trigger BMD measurement; others suggest these should be considered for treatment without the need for further assessment.</li>
<li>Postmenopausal women with risk factors.</li>
<li>Women or men with significant risk factors.</li>
<li>Women or men on oral corticosteroid treatment. (Any dose taken continuously over three months or frequent courses. 7.5 mg prednisolone or equivalent per day over three months continuously is considered high dose by NICE and confers higher risk.)</li>
<li>All women aged over 65 and all men aged over 75 (NICE only)</li>
what is denosumab
a treatment for osteoporosis in people intolerant of bisphosphonates.
what is the mechanism of action of denusomab
blocks action of RANK-L, a powerful stimulant of osteoclast activity
why does low osetrogen cause osteoporosis
in an oestrogen-deficient state, there are more active, longer living osteoclasts, whereas osteoblasts have shorter survival
“this shows a<div><img></img><br></br></div>”
displaced intracapsular fracture
“this shows a<div><img></img><br></br></div>”
extracapsular fracture
“this shows a<div><img></img><br></br></div>”
non-displaced intracapsular fracture
a non-displaced intracapsular fracture can be surgically treated with
“an extramedullary nail<div><img></img><br></br></div>”
a displaced intracapsular fracture can be surgically treated with
“hemiarthroplasty<div><img></img><br></br></div><div>can also be full arthroplasty but more demanding surgery</div>”
an extracapsulary fracture can be treated surgically with
“an intramedullary hip screw<div><img></img><br></br></div>”
why are intracapsulary fractures more serious
“risk of avascular necrosis of femoral head as blood supply cut off<div><img></img><br></br></div>”
why does age increase risk of osteoporosis with regards to bone reabsorption
“<img></img>”
what is the medical term for breathlessness
dyspnoea
what causes breathlessness
The reason for breathlessness is that the body needs more oxygen than it is getting. So you breathe faster to try to increase the flow of oxygen-rich air into the lungs. From the lungs, oxygen gets into the bloodstream and is pumped round the body by the heart.
what can cause severe breathlessness
<b>respiratory:</b><div>pneumonia<div>asthma</div><div><b><br></br></b></div><div><b>cardiac:</b></div><div>lung and heart disease</div><div>heart faliure</div></div>
what is the MRC score system for breathlessness
<ol><li>No breathlessness.</li><li>Breathless on vigorous exertion - for example, running.</li><li>Breathless walking up slopes.</li><li>Breathless walking at normal pace on the flat; having to stop from time to time.</li><li>Stopping for breath after a few minutes on the level.</li><li>Too breathless to leave the house.</li></ol>
what questions should be asked if someone experiences breathlessness (7)
<ul><li>Did it start suddenly or develop over time? Did anything trigger it?</li><li>How far can you walk? Are you only breathless when you move? Is it worse when you lie down?</li><li>Do you feel ill? Do you have a high temperature (fever), weight loss or a cough? Do you have any pain in your chest?</li><li>Are you coughing up any phlegm (sputum)? What colour is it?</li><li>Have you lost weight, coughed up blood, been in contact with anyone with tuberculosis (TB) or travelled abroad recently?</li><li>Have you recently been bed-bound or on a long flight?</li><li>Do you smoke?</li></ul>
what tests may be done on someone with breathlessness
- blood pressure<div>- peak flow and other lung function tests</div><div>- chest X ray</div><div>- blood tests (iron, TSH, heart faliure)</div>
what can cause short-term breathlessness
<b>respiratory:</b><div>asthma<div>pneumonia</div><div>COPD</div><div>pulmonary embolism</div><div><b><br></br></b></div><div><b>cardiac:</b></div><div>heart disease<br></br></div><div><br></br></div><div><b>other:</b></div><div>anxiety</div><div>medications (beta-blocker, aspirin)</div></div>
what can cause chronic breathlessness
<div><b>respiratory:</b></div>
<div>poorly controlled asthma</div>
<div>COPD</div>
<div><br></br></div>
<div><b>cardiac:</b></div>
<div>heart faliure</div>
<div>arrythmias</div>
<div><br></br></div>
<div><b>other:</b></div>
<div>anaemia</div>
<div>obesity and poor fitness<br></br></div>
what can you do if you feel very breathless
<ul><li>Try not to panic, if possible.</li><li>Call 999/112/911 if severe and sudden with no obvious cause.</li><li>Call your GP urgently otherwise.</li><li>Use your reliever inhaler as instructed if you have asthma.</li><li>Use your oxygen if you have been supplied with it.</li></ul>
what can help chronic breathlessness
<ul><li>Relaxed, slow, deep breathing: breathe in gently through your nose and breathe out through your nose and mouth. Try to stay feeling relaxed and calm.</li><li>Paced breathing: this may help when you are walking or climbing stairs. Try to breathe in rhythm with your steps at a speed you find comfortable.</li><li>Controlled breathing. This involves using your diaphragm and lower chest muscles to breathe instead of your upper chest and shoulder muscles. Breathe gently and keep your shoulders and upper chest muscles relaxed.</li></ul>
what is the main cause of preventable illness and premature death in the UK
Smoking tobacco
when do the benefits of smoking cessation begin
as soon as a person stops smoking
why can it be difficult to stop smoking
temporary withdrawal symptoms caused by nicotine dependence
what can temporary withdrawl symptoms from tobacco include
<u>physical:</u><div>nicotine cravings</div><div>sleep disturbances</div><div>increased appetite<br></br></div><div>weight gain</div><div><br></br></div><div><u>psychological:</u></div><div>irritability</div><div>depression</div><div>restlessness</div><div>poor concentration</div><div>light-headedness<br></br></div>
should e-cigarette smokers be advised to stop smoking
yes
what kind of stopping smoking offers the best chance of lasting success
stopping in one step (‘abrupt quitting’)
“what is ‘abrupt quitting’”
when a smoker makes a commitment to stop smoking on or before a particular date (the quit date), rather than by gradually reducing their smoking
what is the most effective approach to smoking cessation
both drug treatment AND psychological support
Smokers who wish to stop smoking should be referred to
their local NHS Stop Smoking Services
what will local NHS Stop Smoking Services provide
advice, drug treatment, and behavioural support options such as individual counselling or group meetings
Smokers who decline to attend their local NHS Stop Smoking Services should be
referred to a suitable healthcare professional who can also offer drug treatment and practical advice
what are the 3 effective drug treatments to aid smoking cessation
“Nicotine replacement therapy (NRT), <a>varenicline</a>, and <a>bupropion hydrochloride</a>”
what are the most effective drug treatment options for smoking cessation
“<a>Varenicline</a><div><br></br></div><div>a combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)</div>”
what may be prescribed for smoking cessation if first line treatment options are not appropriate
“<a>bupropion hydrochloride</a> or single therapy NRT”
should both both varenicline and bupropion hydrochloride be prescribed together
no
should varenicline or bupropion hydrochloride be prescribed alongside NRT
not reccomended
when should drug treatment be made avaliable to someone quitting smoking
treatment should be available before the person stops smoking. Smokers should be prescribed enough treatment to last 2 weeks after their agreed quit date and be re-assessed shortly before their supply finishes
should smokers who are not stopping smoking be offered NRTs
“yes, as part of a ‘harm reduction approach’, because the amount of nicotine in NRT is much lower and less addictive than in smoking tobacco”
can e-cigarettes be prescribed or supplied by smoking cessation services
no
what should be done if a pregnant person is smoking
advise to stop smoking completely<div><br></br></div><div>be informed about the risks to the unborn child, and the harmful effects of exposure to second-hand smoke for both mother and baby</div><div><br></br></div><div>referred to smoking cessation services</div>
should pregnant people who smoke be offered NRT
NRT should only be used in pregnant females if non-drug treatment options have failed. Clinical judgement should be used when deciding whether to prescribe NRT following a discussion about its risks and benefits. Subsequent prescriptions should only be given to pregnant females who have demonstrated they are still not smoking.
can tobacco smoking affect other medications
yes<div><br></br><div>Polycyclic aromatic hydrocarbons found in tobacco smoke increase the metabolism of some drugs by inducing hepatic enzymes, often requiring an increase in dose. Information about drugs interacting with tobacco smoke can be found under <em>Interactions</em> of the relevant drug monograph.<br></br></div></div>
what is the main reason people smoke
addiction to nicotine
where can NRTs be found
pharmacies and some shops<div><br></br></div><div>on prescription from a doctor or NHS stop smoking service.</div>
what are NRTs avaliable as
<ul> <li>skinpatches </li> <li>chewing gum </li> <li>inhalators (which look likeplastic cigarettes) </li> <li>tablets, oral stripsand lozenges </li> <li>nasal and mouth spray</li></ul>
how long does NRT treatment usually last
8-12 weeks, before you gradually reduce the dose and eventually stop
what are side effects of NRTs
“physical:<div><ul> <li>skin irritation when using patches </li> <li>irritation of nose, throat or eyes when using a nasal spray </li> <li>difficulty sleeping<a>(insomnia)</a>, sometimes with vivid dreams </li> <li>an upset stomach </li> <li><a>dizziness</a></li> <li><a>headaches</a></li></ul></div>”
what is the brand name of varenicline
Champix
how does Varenicline work
reduces cravings for nicotine like NRT, but it also blocks the rewarding and reinforcing effects of smoking.
isVarenicline avaliable in pharmacies
no, only on prescription
how shouldVarenicline be used
“<div>It’s taken as 1 to 2 tablets a day. You should start taking it a week or 2before you try to quit.</div> <div>A course of treatment usually lasts around 12 weeks,but it can be continued for longer if necessary.</div>”
what is bupropion hydrochloride
“<div>Bupropion (brand name Zyban) is a medicine originally used to treat <a>depression</a>, but it has since been found to help people quit smoking.</div> <div>It’s not clear exactly how it works, but it’s thought to have an effect on the parts of the brain involved in addictive behaviour.</div>”
what are the 5 fundamentals of COPD care
“<img></img>”
when should inhaled therapies be offered for COPD
“<img></img>”
what should happen regularly with inhaled therapies
review meds<div>assess inhaler technique</div>
what are first line inhaled therapies for COPD
SABA or SAMA to use as needed
SABA stands for
short acting beta antagonists<div>(eg salbutamol)</div>
SAMA stands for
short acting muscarinic antagonist (Eg ipratropium bromide)
LABA stands for
long acting beta antagonistc (eg formoterol, salmeterol)
LAMA stands for
long acting muscarinic antagonists (eg tiotropium, glycopyrrhonium)
what are the 2 steps that should be taken to choose the right inhaler for your patients
- assess inspiratory ability, observe them inhaling using own device if possible<div><br></br></div><div>2.patient engagement and inhaler technique</div><div><br></br></div>
what 2 inhalation manoeuvres should be observed
“<img></img>”
what are the 7 steps for correct inhaler technique
“<img></img><div>Please</div><div>Prepare</div><div>Every</div><div>Meal</div><div>In</div><div>Big</div><div>Containers</div>”
what are spacers
Spacers (or holding chambers) are large, empty devices (or tubes) that are usually made out of plastic. They help you get the best from your asthma medicine if you use a metered dose inhaler (MDI)
how do spacers help
Spacers make it easier to get the right amount of medicine<div><br></br></div><div>Metered dose inhalers (MDIs) deliver a dose of medicine in a fine spray (aerosol) form. It can be difficult to use them correctly as you need to breathe in at exactly the same time as you press down on your inhaler to release the medicine. You also need to breathe in very slowly and deeply.</div><div><br></br></div><div>Using a spacer helps the medicine get straight to your lungs. You fix your inhaler on one end of the spacer, and use the mouthpiece at the other end. When you press on your inhaler, the medicine collects in the chamber of the spacer, so you can breathe it in without needing to get the timing and speed exactly right.</div>
why does using a spacer mean you can use less medicine
“<img></img>”
why does using a spacer reduce the risk of side effects?
Spacers reduce the small risk of side effects if you’re taking preventer (steroid) medicine. Because more of the medicine gets down to your lungs, less medicine is absorbed into the rest of your body, lowering the risk of side effects. This also reduces the risk of voice changes and oral thrush: a fungal infection that can be a side effect of asthma inhalers, particularly in children
“<img></img><div>these are</div>”
pMDI inhalers
what is a pMDI
pressured metered dose inhaler
how is a pMDI inhaler made ready for use
test sprays
what are the steps involved in using a pMDI inhaler
- test spray<div><br></br><div>- shake well</div><div><br></br></div><div>-Sit or stand up straight and slightly tilt your chin up</div><div><br></br></div><div>-Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in</div><div><br></br></div><div>- Put your lips around the mouthpiece of the inhaler to make a tight seal</div><div><br></br></div><div>-Start to breathe in slowly and steadily and at the same time, press the canister on the inhaler once</div><div><br></br></div><div>- Continue to breathe in slowly until your lungs feel full</div><div><br></br></div><div>- Take the inhaler out of your mouth and with your lips closed, hold your breath for up to 10 seconds, or for as long as you comfortably can</div><div><br></br></div><div>-Then breathe out gently, away from your inhaler.</div></div>
“this is a<div><img></img><br></br></div>”
SMI inhaler
what does SMI inhaler stand for
soft-mist inhaler
what is the priming sequence for a SMI inhaler
Hold your inhaler upright, with the cap closed.<div><br></br></div><div>Twist the base in the direction of the arrows until it clicks.</div><div><br></br></div><div>Push up the catch on the side of the inhaler and open the cap.</div><div><br></br></div><div>Point the inhaler towards the floor away from you and press the big grey button.</div><div><br></br></div><div>Close the cap. If you do not see a white cloud, repeat this sequence until you see a cloud.</div><div><br></br></div><div>If you have not used your inhaler for one to three weeks, you will need to repeat this priming sequence once.</div><div><br></br></div><div>If you have not used your inhaler for more than three weeks, you will need to repeat this priming sequence three times in total</div>
how should you use a SMI inhaler
Hold the inhaler upright, with the cap closed.<div><br></br></div><div>Twist the base in the direction of the arrows until it clicks.</div><div><br></br></div><div>Push up the catch on the side of the inhaler and open the cap. Hold the inhaler horizontally.</div><div><br></br></div><div>Check that there is nothing inside the inhaler mouthpiece.</div><div><br></br></div><div>Sit or stand up straight and slightly tilt your chin up, as it helps the medicine reach your lungs.</div><div><br></br></div><div>Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in.</div><div><br></br></div><div>Put your lips around the mouthpiece of the inhaler to make a tight seal without blocking the two holes on either side.</div><div><br></br></div><div>Start to breathe in slowly and steadily and, at the same time, press the big grey button on the inhaler once.</div><div><br></br></div><div>Continue to breathe in slowly until your lungs feel full.</div><div><br></br></div><div>Take the inhaler out of your mouth and hold your breath for up to 10 seconds, or for as long as you comfortably can.</div><div><br></br></div><div>Then breathe out gently, away from your inhaler. When you have finished, replace the cap on the inhaler.<br></br></div>
“what should you do if you’ve used an inhaler containing steroids”
If you’ve used an inhaler that contains steroids, rinse your mouth with water and spit it out to reduce the chance of side effects.
“this is a<div><img></img><br></br></div>”
DPI inhaler
what does DPI stand for
dry powder device
“this shows a<div><img></img><br></br></div>”
spacer
what are differential diagnoses for shortness of breath on excertion
“<img></img>”
what are examples of restrictive lung disease
“<img></img>”
what are examples of obstructive lung disease
“<img></img>”
what are signs of hyperinflation on CXR
“<img></img>”
GORD stands for
gastro-oesophageal reflux disease
what are the two main symptoms of acid reflux
<ul><li>heartburn – a burning sensation in the middle of your chest</li><li>an unpleasant sour taste in your mouth, caused by stomach acid</li></ul>
what can be four other symptoms of acid reflux, after heartburn and sour tastes
<ul><li>a cough or hiccups that keep coming back</li><li>a hoarse voice</li><li>bad breath</li><li>bloating and feeling sick</li></ul>
when are symptoms of acid reflux generally worse
after eating, when lying down and bending over
what can cause acid reflux or make it worse (3)
lifestyle factors: diet (coffee, spicy food), overweight, smoking, stress<div><br></br></div><div>co-morbidities: pregnancy, hiatus hernia</div><div><br></br></div><div>drugs: NSAIDs</div>
what positive lifestyle changes may stop or reduce heartburn
- smaller, more frequent meals,<div>- raise your chest and head at night</div><div>- weight loss</div><div>- reduced stress</div>
what should you stop doing if you have heartburn
- trigger foods<div>- eating 3 to 4 hrs before bed</div><div>- smoking/drinking</div>
who can help with heartburn other than a GP
pharmacist - prescribe antacids
when should you see a GP with heartburn
<ul><li>lifestyle changes and pharmacy medicines are not helping</li><li>you have heartburn most days for 3 weeks or more</li><li>you have other symptoms, like food getting stuck in your throat, frequently being sick or losing weight for no reason</li></ul>
what medications may a GP prescribe for heartburn
PPIs (eg omeprazole or lomeprazole)
what further investigations may be carried out for heartburn
“<ul><li>tests to find out what’s causing your symptoms, such as a <a>gastroscop</a>y(where a thin tube with a camera is passed down your throat)</li><li>an operation on your stomach to stop acid reflux – called a laparoscopic fundoplication</li></ul>”
what is dyspepsia
“<img></img>”
“<img></img><div>is described as</div>”
dyspepsia
why is dyspepsia a good term to use
“doesn’t imply a cause, so broad differential”
when the cause of dyspepsia is oesophageal reflux, what other symptoms may be associated
watering in the mouth<div>acidic taste in the mouth</div>
when the cause of dyspepsia is gastroenteritis, what other symptoms may be associated
nausea, vomiting, diahoerrea
what are the most common causes of dyspepsia
- GORD<div>- functional dyspepsia</div><div>- gastritis</div><div>- peptic ulcer disease</div>
what can be found on endoscopy with functional dyspepsia
- some insignificant gastritis<div>- nothing</div>
what can cause severe gastritis
- infection<div>- NSAIDs</div><div>- alcohol abuse</div>
what can gastritis lead to
ulceration
what causes oesophagitis
GORD - acid in oesophagus
peptic ulcer disease refers to ulcers where
stomach and duodenum
what are key symptoms of GORD
- burning pain behind the sternum<div>- symptoms are worse after eating and lying down</div>
what is colicky pain
intermittent, spasmodic pain when a hollow tube contracts to try and remove an obstruction
what causes colicky pain
- gallstones<div>- kidney stones</div><div>- intestinal obstruction</div>
what may be associated with pancreatitis
steathorrea and DM
what is atypical pain for coronary heart disease
dyspepsia
what is a serious cause of dyspepsia
upper GI malignancy
“what are ‘red flag’ symptoms”
indicate a potentially serious underlying condition
what are 4 red flags for back pain
“<img></img>”
what are red flags for headaches
“<img></img>”
where is a good place to identify red flag symptoms
referral guidelines
what are NICE guidelines for suspected upper GI cancer referal
“<img></img>”
an upper abdominal mass consistent with stomach cancer should cause
urgent 2 week cancer referral
urgent upper GI endoscopy should be offered
<div>- dysphagia</div>
<div>- 55+, weight loss and one of upper abdo pain, dyspepsia, reflux</div>
when should an non-urgent endoscopy be ordered
”- haematesis<div>- 55+, vomiting, low haemoglobin, raised platelets</div><div><img></img><br></br></div>”
what are red flag signs and symptoms for upper GI cancer
- upper abdo mass<div>- dysphagia</div><div>- weight/appetite loss</div>
what medications can affect reflux
“<img></img>”
what diseases is H pylori associated with
“<img></img>”
what are FBC cancer red flags
- anaemia<div>- thrombocyosis</div>
why can upper GI tract cancers cause anaemia
- occult blood loss<div>- cytokines</div>
when are stool tests indicated
“<img></img>”
when are abdominal radiographs useful
“<img></img>”
what is melaena
dark and offensive smelling stool with digested blood
what cells in the stomach produce alkaline mucus
Foveolar cells
how does H pylori deal with the low stomach pH when not burrowed into the epithelium
produces urease to break down urea in stomach to CO2 and ammonia, which neutralise strong acids
how does H pylori reach the mucus layer
chemotaxis and flagella
most people with a H pylori infection are
asymptomatic
is adhesion to the host by H pylori harmful
no
what H pylori toxin causes disruption of the tight junctions between gastric epithelial cells
cagA
what H pylori toxin causes gastric cells to undergo apoptosis
vacA
what does vacA do
causes gastric cells to undergo apoptosis
what does cagA do
causes disruption of the tight junctions between gastric epithelial cells
in combination, vacA and cagA disrupt
the lining of the stomach, exposing cells to acid
are all strains of H pylori harmful
no
what % of the world population have H pylori in their stomach
50%
what tests does NICE recommend as a first test for H pylori infection
Carbon-13 urea breath test<div>stool antigen test</div>
what are 4 tests for H pylori
CLO test<div>stool antigen test</div><div>serum antibody test</div><div>Carbon-13 urea breath test</div>
which tests for H pylori test for Hy pylori proteins
CLO test<div>stool antigen test</div><div>Carbon-13 urea breath test</div>
which test for H pylori tests for human proteins
serum antibody test
why is the serum antibody test not good for diagnosis
“don’t know if infection is current or past”
the inside of the stomach is called the
lumen
which cells secrete hydrochloric acid
parietal cells
which side of a cell faces a lumen
apical side
which side of a cell faces a capillary
basolateral side
how does hydrogen pass into the gastric lumen from the parietal cell
gastric hydrogen postassium ATPase
how do H2 (histamine) receptors increase HCl production
increase numbers of proton pumps in apical membrane
PPIs reduce the amount of HCl and also
- anti-urease and anti-ATPase activity<div>- weak antibacterial activity</div>
how do PPIs enhance the effects of antibiotics
decrease the amount of acid making the antibiotic more concentrated
how much of acid production is blocked by PPIs
80%
what are 3 kinds of drugs which decrease acid in the stomach
H2 antagonists<div>Proton Pump Inhibitors</div><div>Antacids</div>
what are 2 PPIs
omeprazole, lanzeprazole
what are 2 antacids
magnesium carbonate<div>aluminium hydroxide</div>
what are 2 H2 antagonists
<div>cimetidine</div>
<div>rantidine</div>
what is the only test validated by NICE for cure of H pylori
carbon-13 urea breath test
why should the carbon-13 breath test be preceded by 2 weeks of no PPIs and 4 weeks of no antibiotics
prevent false negatives
what should the carbon-13 urea breath test be preceded by
2 weeks of no PPIs and 4 weeks of no antibiotics
fluid that refluxes into the oesophague is usually
acidic
when can non-acid reflux occur
- ingested food buffers stomach acid
can bile reflux into the oesophagus
yes, rarely if duodenal contents reflux into stomach
when will PPIs not help
- functional dyspepsia<div>- non-acid reflux</div><div>- acid production insufficiently depressed</div>
what are the 2 kinds of hiatus hernia
sliding and rolling
what sex is more at risk of hiatus hernia
males
what can cause a hiatus hernia
- widening of diaphragmatic hiatus<div>- pulling up of stomach (eg oesophageal shortening)</div><div>- pushing up of stomach (increased abdo pressure)</div>
what is the most common kind of hiatus hernia
sliding
“what kind of hiatus hernia is this<div><img></img><br></br></div>”
sliding
“what kind of hiatus hernia is this<div><img></img><br></br></div>”
rolling
what can be used to treat non-acid reflux
alginate medication like gaviscon
how do alginates work
react with stomach contents to form a foamy raft that floats on top of stomahc contents
“what phenomenon occurs in Barrett’s”
metaplasia
“cardiac metaplasia in Barrett’s refers to”
cells like the cardia in the stomach
what are other names for high grade, non-invasive cells
“<img></img>”
“Barrett’s patients have what every few years”
OGD + biopsy
“are people with GORD commonly monitored for Barrett’s”
no, unless they have a family history or other risk fatcors
what are treatment options for a carcinoma in situ
mucosal resection, radiofrequency ablasion, oesophagectomy
how may smoking exacerbate reflux
nicotine may relax lower oesophageal sphincter
what medications may cause dyspepsia
calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and nonsteroidal anti-inflammatory drugs [NSAIDs]
how isdyspepsia in unselected people in primary care defined
broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting
Leave a 2-week washout period after proton pump inhibitor (PPI) use before
testing for<em>Helicobacter pylori</em>with a breath test or a stool antigen test
what should be offered if dyspepsia does not respond to a PPI
H2 rantidine therapy
what is first line treatment for H pylori infection
“offer people who test positive for <em>H pylori</em> a 7-day, twice-daily course of treatment with: <ul> <li>a PPI <span>and</span></li> <li>amoxicillin <span>and</span></li> <li>either clarithromycin or metronidazole<br></br></li></ul>”
what are biomarkers for diabetic nephropathy
proteinurea<div>high serum creatinine</div>
how many people with diabetes deveelop kideny faliure
1 in 5
what is the leading cause of kidney faliure
diabetes
if you have diabetes, what should happen at least once a year
urine and blood test for kidney function
what are risk factors for chronic kidney disease (8)
are African-Caribbean, Black African and South Asian and over the age of 25<div><br></br></div><div>• have a blood relative who has diabetes<div><br></br></div><div>• have high blood pressure<div><br></br></div><div> • are overweight, especially around your middle<div><br></br></div><div>• smoke<div><br></br></div><div>• have other complications from diabetes, such as retinopathy<div><br></br></div><div>• poor control of blood glucose levels<div><br></br></div><div>• have protein in your urine</div></div></div></div></div></div></div>
what is the staging system to assess levels of proteinurea
A1, A2, 13
A1 means
hardly any protein in your urine
if there is hardly any protein in your urine, you will be staged as
A1
if there is a small amount of protein in your urine, you will be staged as
A2
if there is a large amount of protein in your urine, you will be staged as
A3
A2 means
a small amount of protein in your urine
A3 means
a large amount of protein in your urine
what is eGFR
a measurement of how many millilitres (ml) of blood is cleaned by your kidneys each minute (measured in ml/min).
what are the units of eGFR
ml/min
what is the normal eGFR in young fit people
80-100ml/min
