CSI Flashcards
1
Q
why is influenza more dangerous
A
it preferentially binds to receptors in the lower respiratory tract
2
Q
what are the 3 membrane glycoproteins on Influenza A
A
haemagglutinin (HA), neuraminidase (NA) and Matrix-2 (M2)
3
Q
Influenza B shares which two glycoproteins with A
A
HA and NA + two others
4
Q
does influenza C cause lower respiratory tract complications
A
only rarely
5
Q
haemagglutin acts as (2)
A
an attachment factor and membrane fusion
6
Q
HA binds to
A
sialic acid (to enter cell)
7
Q
HA binding to sialic acid on RBCs causes
A
haemagglutination
8
Q
Neuraminidase is a
A
glycoside hydrolase enzyme
9
Q
neuraminidas allows the virus to be
A
released from cells (not stuck to sialic acid)
10
Q
natural mutation over time and happens continuously, in all viruses is called
A
antigenic drift
11
Q
genetic reassortment that yields a phenotypic change in viruses is called
A
antigenic shift
12
Q
over time, antigenic shift can lead to (2)
A
loss of immunity<div>vaccine mismatch</div>
13
Q
antigenic shift only happens in
A
influenza A
14
Q
antigenic shift means that immediately, most people have
A
no immunity
15
Q
why does antigenic shift only happen in infleunza A
A
other types of Influenza are not able to infect other animals (whichis essential for allowing reassortment)
16
Q
what are the most common cold symptoms (3)
A
- mild cough/sore throat<div>- sneezing</div><div>- post-nasal drip</div>
17
Q
what are the most common flu symptoms (4)
A
- cough<div>- fever</div><div>- fatigue</div><div>- headache</div>
18
Q
what are common symptoms of COVID (3)
A
- loss of taste/smell<div>- fever</div><div>- cough</div>
19
Q
what is the most common cold virus
A
rhinovirus
20
Q
rhinovirus interacts with which cell membrane protein?
A
ICAM-1
21
Q
coronavirus interacts with which cell membrane protein?
A
ACE2
22
Q
“What are Zola’s triggers (5)”
A
“<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>”
23
Q
“According to Helman’s folk model of illness, what does the patient want to know from their doctor?”
A
“<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>”
24
Q
ICE stands for?
A
Ideas, Concerns, Expectations
25
in sickle cell haemoglobin, hydrophilic glutamate 6 is replaced by
hydrophobic valine 6
26
which form of HbS can polymerise
deoxygenated
27
what are the main symptons of sickle cell disease (3)
- sickle cell crises
- increased infection risk
- anaemia
28
how might a patient self-manage a sickle crisis
- painkillers
- staying warm, warming pads
- drinking fluids
29
how does drinking fluids prevent a sickle crisis
keeps blood thin and flowing well
30
how does staying warm prevent a sickle cell crisis
keeps peripheral blood vessels open
31
why are patients with sickle cell prescribed antibiotics
functional splenectomy
32
what are two medical treatments that can be given in an acute sickle crisis
- hydroxycarbamide
- blood transfusion
33
what might you see on the blood test of someone with sickle cell anaemia (2)
- higher reticulocyte count, and thus increased MCV
- low Hb
34
why are bone crises common in sickle cell anaemia
"- smaller blood vessels so easily 'clogged' by sickled erythrocytes"
35
why might visual loss occur in a patient with sickle cell anaemia?
- blocked blood vessels in the eye
- leads to shoddy blood vessel formation to bypass blockage
- shoddy vessels break causing retinal haemorrhage and in some cases retinal detachment
36
are patients with sickle cell at higher risk of stroke
yes
37
why might a person with sickle cell anaemia take vitamin B12 and folate
manage anaemia and rapid RBC turnover
38
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
39
ischaemic stroke is caused by
blood clots
40
why does sickle cell anaemia cause gallstones
buildup of bilirubin from RBC destruction
41
why might Howell-Jolly bodies be seen on the blood film of a patient with sickle cell anaemia
functional splenectomy
42
why might cardiac hypertrophy be seen in sickle cell anaemia
need to pump more blood to compensate for anaemia
43
what kind of anaemia is SCA
normocytic with high reticulocyte count
44
Which complication associated with sickle cell disease is most associated with significant memory impairment?
stroke
45
What is the most common central nervous system disorder associated with sickle cell disease?
Depression
46
what are healthcare associated infections
infections that patients get while receiving treatment for medical or surgical conditions
47
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).
48
what are 5 common HAIs
- Catheter-associated urinary tract infections
- Surgical site infections
- Bloodstream infections
- Pneumonia
- Clostridium difficile
49
what are the three main types of risk factors for HAIs
medical procedures and antibiotic use, organizational factors, and patient characteristics
50
what can help to reduce rates of HAIs
proper education and training of health care workers
51
many HAIs are
preventable
52
the traditional epidemiologic triad model holds that infectious diseases result from
the interaction of agent, host, and environment
53
The reservoir of an infectious agent is the
habitat in which the agent normally lives, grows, and multiplies
54
is the reservoir necessarily the source from which an agent is transferred to a host
no; for example the reservoir of Clostridium botulinum is soil, but the source of most botulism infections is improperly canned food containing C. botulinum spores.
55
Asymptomatic or passive or healthy carriers are
those who never experience symptoms despite being infected
56
Incubatory carriers are
those who can transmit the agent during the incubation period before clinical illness begins
57
Reservoirs include (3)
humans, animals, and the environment
58
Chronic carriers are
those who continue to harbor a pathogen such as hepatitis B virus or Salmonella Typhi, the causative agent of typhoid fever, for months or even years after their initial infection.
59
Carriers commonly transmit disease because
they do not realize they are infected, and consequently take no special precautions to prevent transmission
60
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
61
The term zoonosis refers to
an infectious disease that is transmissible under natural conditions from vertebrate animals to humans
62
The portal of exit usually corresponds to
the site where the pathogen is localized
63
what is direct transmission
an infectious agent is transferred from a reservoir to a susceptible host by direct contact or droplet spread
64
direct contact occurs through
skin-to-skin contact, kissing, and sexual intercourse, and also contact with soil or vegetation harboring infectious organisms
65
Droplet spread refers to
spray with relatively large, short-range aerosols produced by sneezing, coughing, or even talking
66
Indirect transmission 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).
67
Airborne transmission occurs when
infectious agents are carried by dust or droplet nuclei suspended in air.
68
droplet nuclei may remain suspended in the air for
long periods of time
69
Vehicles 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).
70
what is a fomite
inanimate objects such as handkerchiefs, bedding, or surgical scalpels that can spread an infectious agent
71
Vectors such as mosquitoes, fleas, and ticks
carry an infectious agent through purely mechanical means or support growth or changes in the agent.
72
The portal of entry refers to
the manner in which a pathogen enters a susceptible host
73
The final link in the chain of infection is
a susceptible host
74
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
75
public health interventions are aimed at (3)
- Controlling or eliminating agent at source of transmission
- Protecting portals of entry
- Increasing host’s defenses
76
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.
77
what should we consider for a condition
impact on safety, system and resources
78
"how can we find out a bacteria's sensitivities?"
"Antibiotic Sensitivity test![]()
"
79
what are empiric antibiotics
antimicrobials are given to a person before the specific bacterium is known, anticipate likely cause of disease
80
why might a patient develop diarrhoea after antibiotic therapy
C difficile overgrowth following microbiome damage
81
what is candour
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82
what is empathy
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83
what can antibiotic-resistant infections require (3)
extended hospital stays, additional follow-up doctor visits, and costly and toxic alternatives.
84
name 3 medical advances dependant on antibiotics
organ transplants, cancer therapy, and treatment of chronic diseases like diabetes, asthma, and rheumatoid arthritis
85
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.
86
how should we prescribe antibiotics (4)
Always prescribe the right antibiotic, at the right dose, for the right duration, and at the right time.
87
what are common side effects of antibiotics (5)
rash, dizziness, nausea, diarrhea, and yeast infection
88
what does penicillin disrupt
creation of the cell wall
89
how does penicillin work
triggers lysis by preventing peptidoglycan cell wall creation
90
what is the active part of penicillin
beta-lactam ring
91
how is MRSA resistant to penicillin
"encodes alternative PBP which beta-lactams can't bind to"
92
why is the NDM1 gene plasmid so dangerous
encodes a beta-lactamase that is effective against almost all known beta lactams
93
how does co-amoxiclav work
amoxicillin and clavuamic acid which blocks beta-lactamase
94
what is dementia
a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities
95
is dementia a normal part of ageing
no
96
what is the most common form of dementia
"Alzheimer's disease"
97
does dementia affect consciousness
no
98
what does dementia affect (8)
memory,
thinking,
orientation,
comprehension,
calculation,
learning capacity,
language,
judgement.
99
what is the impairment in cognitive function typically accompanied by
deteriortion in emotional control and soical behaviour
100
what are the three stages of dementia
early, middle, and late
101
what are three common symptoms of early stage dementia
102
what are five common symptoms of middle stage dementia
"becoming forgetful of recent events and people's names becoming lost at home having increasing difficulty with communication needing help with personal care experiencing behaviour changes, including wandering and repeated questioning "
103
whar are five common symptoms of late stage dementia
104
"what are common forms of dementia other than Alzheimer's (3)"
vascular dementia,
dementia with Lewy bodies (abnormal aggregates of protein that develop inside nerve cells),
frontotemporal dementia (degeneration of the frontal lobe of the brain)
105
what is the estimated proportion of the general population aged 60 and over with dementia at a given time?
5-8%
106
what are the principal goals for dementia care (5)
- early diagnosis in order to promote early and optimal management
- optimizing physical health, cognition, activity and well-being
- identifying and treating accompanying physical illness
- detecting and treating challenging behavioural and psychological symptoms
- providing information and long-term support to carers.
107
what are known physical risk factors for dementia (7)
- age
- lack of exercise
- smoking
- alcohol abuse
- BMI
- diet
- BP, cholesterol, BG
108
what are known psychosocial risk factors for dementia (4)
- depression
- low educational attainment
- social isolation
- cognitive inactivity
109
what is mild cognitive impairment
- minor problems with cognition
- worse than expected for healthy person of same age
- not severe enough to interfere with daily life (so not dementia)
110
how many people over 65 have MCI
5-20%
111
A person with MCI has mild problems with one or more of the following - VALMR (5)
- memory - for example, forgetting recent events or repeating the same question
- reasoning, planning or problem-solving - for example, struggling with thinking things through
- attention - for example, being very easily distracted
- language - for example, taking much longer than usual to find the right word for something
- visual depth perception - for example, struggling to interpret an object in three dimensions, judge distances or navigate stairs.
112
In someone with MCI, however, the decline in mental abilities is greater than in
normal ageing
113
what can cause MCI (7)
"- 'pre-dementia'
- depression
- anxiety
- physical illness
- poor eyesight/hearing
- vitamin/thyroid deficiency
- medication side effects
"
114
do people with MCI have an increased risk of developing dementia
yes but not at all guaranteed
115
how can MCI be treated (5)
- control heart problems, diabetes
- prevent stroke
- stop smoking/drinking
- exercise and diet
- mental and social activity
116
what are the benefits of diagnosing MCI
- identify and support patients at increased risk of dementia
117
what are four interventions that either prevent occurence or delay onset of dementia/MCI
Physical activity
Mediterranean diet
Not smoking
Not drinking to excess
118
what post-diagnostic interventions can be made after a diagnosis of MCI/dementia (4)
Social isolation
Cognitive stimulation
Prompt treatment of infection
Prompt treatment of depression
119
what are the three kinds of cognitive intervention
Cognitive Stimulation, Cognitive Training, and Cognitive Rehabilitation
120
what is cognitive stimulation
Cognitive stimulation comprises involvement in group activities that are designed to increase cognitive and social functioning in a nonspecific manner.
121
what is cognitive training
Cognitive training is a more specific approach, which teaches theoretically supported strategies and skills to optimize specific cognitive functions.
122
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)
123
what is reminsicence therapy
enable or encourage people to think or talk about personally significant eventsthat occurred in the past
124
what are other potentially helpful interventions for people with dementia/MCI
- music therapy
- art therapy
- improving living environment
- excercise (as lifestyle change)
125
what is a MDT
combination of professionals from different clinical disciplines and with specific expertise, that work together to optimise a patient’s care
126
what is a MDM
meeting between individuals, or representatives of these different groups/specialties, to plan the best care for a patient.
127
how can we assess memory
cognitive screening test
128
"what are characteristic features of Alzheimer's "
- most common type
- gradual onset
129
what are characteristic features of Vascular Dementia
stepwise progression
130
what are characteristic features of Lewy body dementia
visual hallucinations
131
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
132
what are neurofibrillary tangles
However, when Tau is hyper-phosphorylated, it oligomerises and aggregates into filamentous neuro-fibrillary tangles (NFTs)
133
"many drug treatments for Alzheimer's disease focus on"
replacing acetylcholine lost via death of neurones in the nucleus basalis of Meynert
134
"what are four cerebral features of Alzheimer's"
(1) amyloid plaques,
(2) neurofibrillary tangles,
(3) synaptic deterioration and neuronal death
(4) cerebro-cortical atrophy.
135
"name 3 regions associated with the limbic system implicated in Alzheimer's"
- cingulate gyrus
- hippocampus
- thalamus
136
name 4 people who might be part of an MDT for a MCI patient
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137
when is the mental health act used instead of the mental capaciy act
"![]()
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138
give five examples of people who may lack capacity
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139
does lacking the capacity to make a specific decision mean that you lack capacity to make any decision
"no![]()
"
140
when should we assume someone does not have the capacity to make a decision
when this is proven
141
can you have capacity to make an unwise decision
yes
142
decisions made for people lacking capacity must
be in their best interests and least restrictive of their basic rights and freedoms
143
people should be provided with
an independant advocate
144
what test of capacity does the MCA set up
2 stage:
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?
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.
145
"a person is unable to make a decision if they can't"
"![]()
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146
"Before deciding a person lacks capacity, it's important to "
take steps to enable them to try to make the decision themselves
147
how can we take steps to enable them to try to make the decision themselves?
"![]()
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148
"according to the MCA, how do we decide what's in a patient's best interests"
"![]()
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149
"who else should we consult for views about a patient's best interests"
"![]()
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150
what should we try to find before making a decision or act on behalf of someone who lacks capacity
the least restrictive alternative
151
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
152
the local authority will grant legal authorisation
if the deprivation of liberty is in the best interests of the individual concerned
153
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."
154
what might an advance statement contain
"![]()
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155
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.
156
an advance decision must
be valid and applicable to current circumstances.
157
If the advance decision refuses life-sustaining treatment, it must
- be in writing, signed and witnessed
- state clearly that the decision applies even if life is at risk
158
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
159
When acting under an LPA, an attorney (the appointed person) must
"
- make sure the MCA's statutory principles are followed
- 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
160
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.
161
what is the role of the court of protection
"The Court of Protection 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."
162
"what are 7 typical early symptoms of Alzheimer's (MCMCMRL)"
163
"what are serious symptoms of late Alzheimer's (not just early ones getting worse)"
164
what are specific symptoms of vascular dementia (4) SPMS
- Slower thinking - taking more time to process information and to form thoughts and sentences.
- Personality changes – people may become low in mood, more emotional or lose interest in what’s happening around them.
- Movement problems - difficulty walking or changes in the way a person walks.
- Stability – unsteadiness and falls.
165
What are specific symptoms to dementia with Lewy Bodies (SMASH U)
- Changes in Alertness and attention, and periods of confusion, that may be unpredictable and change from hour-to-hour or day-to-day.
- Movement problems - Parkinson’s-type symptoms such as slower movements, stiffness in the arms and legs, and shaking or trembling.
- Unsteadiness and falls.
- Visual Hallucinations – Seeing things that are not really there, e.g. people or animals. These often happen repeatedly and are realistic and well-formed.
- Sleep disturbances - Vivid dreams, shouting out or moving while sleeping which can disrupt sleep, and may cause injury.
- Sense of Smell – Problems detecting smells.
166
what are 3 types of frontotemporal dementia
behavioural variant frontotemporal dementia
semantic dementia
progressive non-fluent aphasia
167
In behavioural variant frontotemporal dementia, the parts of the frontal lobe that control what may be most affected
social behaviour
168
In semantic dementia, the parts of the temporal lobe that support what are most affected.
understanding of language and factual knowledge
169
In progressive non-fluent aphasia, the parts of the frontal lobe that control what are most affected.
speech
170
what are specific symptoms of frontotemporal dementa (MAILO)
171
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.
172
what are other names for pre-diabetes
- borderline diabetes
- Impaired Fasting Glucose (IFG)
- Impaired Glucose Tolerance (IGT)
- Impaired Glucose Regulation (IGR)
- Non-diabetic hyperglycaemia
173
"what is the target range HbA1C if you're at risk of developing T2DM"
below 42mmol/mol
174
does pre-diabetes mean you will get T2DM
No, but you need ot act to avoid it
175
what are symptoms of pre-diabetes
"Prediabetes doesn’t have any symptoms. If you start to have any of the symptoms of type 2 diabetes it means you have probably already developed it."
176
how many people are at increased risk of T2DM in the UK
12.3 million
177
how many cases of T2DM can be prevented
3 in 5
178
what can significantly reduce your risk of T2DM
losing 5% of your body weight
179
how can T2DM be prevented
- manage weight
- healthy diet
- be more active
180
what kind of diet increases your risk of T2DM
"if your diet is made up of food and drinks with high fat, high GI (short for glycaemic index) and low fibre"
181
what kinds of diet have been linked with a decreased risk of T2DM
- Mediterranean diet
- Dietary Approaches to Stop Hypertension (DASH) diet
- vegetarian and vegan diets
- the Nordic diet
- moderately cutting down on carbohydrates.
182
what is a sedentary lifestyle
spend a lot of time sitting down
183
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
184
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
185
diabetes currently accounts for what proportion of the NHS budget
10%
186
what are the long-term aims of the NHS DPP
To reduce the incidence of Type 2 diabetes;
•To reduce the incidence of complications associated with diabetes - heart, stroke, kidney, eye and foot problems related to diabetes; and
•Over the longer term, to reduce health inequalities associated with incidence of diabetes
187
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.
188
what are the three core goals of the NHS DPP
achieving a healthy weight
•achievement of dietary recommendations
•achievement of CMO physical activity recommendations
189
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
190
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
191
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;
•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;
and •Those who are identified with non-diabetic hyperglycemia through opportunistic assessment as part of routine clinical care.
192
in T2DM, what contributes to progressive failure in the function of β-cells
β-cell resistance to the incretin ‘glucagon-like peptide 1’ (GLP1)
193
in T2DM, what contributes to the excessive glucose production by the liver
increased glucagon levels and enhanced hepatic sensitivity to glucagon
194
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
195
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
196
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.
197
What two other factors cause hyperglycaemia in T2DM
- inflammation
- vascular insulin resistance
198
what are symptoms of T2DM
- peeing more than usual, particularly at night
- feeling thirsty all the time
- feeling very tired
- losing weight without trying to
- itching around your penis or vagina, or repeatedly getting thrush
- cuts or wounds taking longer to heal
- blurred vision
199
what are 4 risk factors for T2DM
- are over 40 (or 25 for south Asian people)
- have a close relative with diabetes (such as a parent, brother or sister)
- are overweight or obese
- are of Asian, African-Caribbean or black African origin (even if you were born in the UK)
200
Impaired insulin secretion in T2DM is caused by pancreatic β-cell dysfunctioning owing to (3)
lipotoxicity, glucotoxicity and resistance to incretins (intestinal hormones that stimulate insulin secretion).
201
Causes of the insulin resistance include
genetic abnormalities
ectopic lipid accumulation
mitochondrial dysfunction
inflammation
endoplasmic reticulum stress
202
What does metformin do
target hepatic glucose production
203
what is the single most important risk factor for T2DM
BMI >25
204
Screening for T2DM is recommended for adults who are (3)
≥45 years of age, obese and/or have a family history, especially since randomized controlled clinical trials have shown that intensive lifestyle interventions, sometimes combined with medication, are effective in delaying and even preventing T2DM.
205
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
206
"what is the ""vicious cycle"" in T2DM"
"![]()
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207
in impaired fasting glucose what is higher than normal
"fasting glucose but nothing else![]()
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208
in impaired glucose tolerance what is higher than normal
"post-prandial glucose - NOT random glucose but fasting glucose may be high![]()
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209
in diabetes what is higher than normal
"all of fasting, post-prandial, and random glucose![]()
"
210
what are advantages of the HbA1C test
- cheap
- easily avaliable
- no need to fast
211
what are disadvantages of the HbA1C test
- average over past 3 months
- not suitable in patients with anaemia or haemoglobinopathies
212
how many people in the UK have diabetes (including undiagnosed)
1 in 16
213
what is metabolic syndrome
"![]()
"
214
what is the EAST framework for behavioural change
"![]()
"
215
how many adults over 65 who live at home will have at least one fall a year?
1 in 3
216
how many adults over 65 who live at home will have more frequent falls?
1 in 6
217
do most falls result in serious injury
no
218
what can happen after a fall
"there's always a risk that a fall could lead to broken bones, and it can cause the person to lose confidence, become withdrawn, and feel as if they have lost their independence."
219
"what should you do if you have a fall but aren't hurt (6)"
"- keep calm and don't get up quickly
- roll onto your hands and knees
- look for a stable piece of furniture
- hold onto the furniture with both hands to support yourself
- when you feel ready, slowly get up
- sit down and rest for awhile
"
220
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 aid call button (if you have one)
- if possible, crawl to a telephone and dial 999 to ask for an ambulance
- try to reach something warm, such as a blanket or dressing gown, to put over you, particularly your legs and feet
- stay as comfortable as possible and try to change your position at least once every half an hour or so
"
221
why are older people more likely to fall (3)
"
- balance problems and muscle weakness
- poor vision
- a long-term health condition, such as heart disease, dementia or low blood pressure (hypotension), which can lead to dizziness and a brief loss of consciousness
222
what can make a fall more likely
- floors are wet, such as in the bathroom, or recently polished
- the lighting in the room is dim
- rugs or carpets are not properly secured
- the person reaches for storage areas, such as a cupboard, or is going down stairs
- the person is rushing to get to the toilet during the day or at night
- falling from a ladder while carrying out home maintenance work.
223
what health condition can make falls especially dangerous in the elderly
osteoporosis
224
what raises your risk of osteoporosis
- smoking
- excessive alcohol drinking
- steroids
- family history of hip fractures
- post-menopausal
225
what are simple measures to prevent falls at home (5)
- using non-slip mats in the bathroom
- mopping up spills to prevent wet, slippery floors
- ensuring all rooms, passages and staircases are well lit
- removing clutter
- getting help lifting or moving items that are heavy or difficult to lift
226
"what can your GP do if you're at risk of falls"
- check your balance
- medications review
- sight test
- ECG and BP test
- request a home hazards assessment
- excercises to improve strength and balance
227
what is it called when a healthcare professional visits your home to identify potential hazards and give advice
home hazard assessment
228
what is a hip fracture
bony injury of the proximal femur typically occurring in the elderly
229
how much do hip fractures cost the NHS and social care per year
£1bn
230
what is the mean age of a hip fracture patient
80
231
how much more common are hip fractures in women
x4
232
what are the 3 sources of blood for the femoral head
- retinacular vessels
- foveal artery
- metaphyseal vessels
233
what is the main blood supply to the femoral head
"retinacular vessels, supplied by medial and lateral circumflex ![]()
"
vessels
234
"![]()
1 shows the
"
retinacular vessels
235
"![]()
2 shows the
"
foveal artery
236
"![]()
3 shows the
"
metaphyseal vessels
237
how may hip fractures be classified relative to the inter-trochantic line
- Above = intra-capsular
- Below = extra-capsular
238
a fracture above the inter-trochantic line is
intra-capsular
239
a fracture below the inter-trochantic line is
extra-capsular
240
"what is Garden's classification of intra-capsular fractures"
- Type I - Incomplete, impacted in valgus
- Type II - Complete, undisplaced
- Type III - Complete, partially displaced
- Type IV - Complete, completely displaced
241
what are risk factors of hip fractures (7)
"
- Increasing age
- Osteoporosis
- Low muscle mass
- Steroids
- Smoking
- Excess alcohol intake
- Metastatic spread of cancer to bone
242
what normally causes hip fractures in the elderly
falls
243
what are mechanisms of hip fractures
- direct falls
- twisting
244
what are bones at risk of hip fracture usually
osteopaenic (reduced bone density) and also deficient in elastic reserve (i.e. they are very brittle).
245
what causes hip fractures in younger patients
- major trauma
- gait disturbance (eg MS)
- medications (eg prolonger corticosteroid use)
246
how are hip fractures diagnosed
Hip fractures are diagnosed radiologically, but may be suspected clinically.
247
is it normal for hip fractures to occur with no precipitating trauma
no
248
what 3 things is it important to elucidate in a fracture history
why an individual may have fallen
whether the fall was mechanical in nature (e.g. slipped on a wet floor)
if the event was precipitated (e.g. MI, stroke, chest infection, UTI etc.)
249
what are symptoms of hip fracture
- Hip / knee pain
- Inability to bear weight
- Limited range of motion
250
what are signs of hip fracture
- Bony tenderness over affected hip
- Shortened / externally rotated leg (only present if significant displacement)
251
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
252
"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![]()
"
253
what is initial management of a hip fracture
analgesia, routine investigations and pre-operative work-up
254
what are routine hip fracture investigations
- routine bloods
- 2 group and save
- chest x ray
- cognitive status
- catheterisation
- urine dipstick and midstream urine if relevant
255
should NSAIDs be given to hip fracture patients
"it's discouraged"
256
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.
257
why may regular medication need to be adjusted following hip fracture
may have acute kidney injury
258
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 PCI for example discussion with cardiology / cardiothoracic surgery is warranted. Where reversal of anticoagulation or coagulopathy is needed discuss with haematology.
259
how are most hip fractures treated
surgically
260
what are NICE guidelines on hip surgery for fractures
NICE guidelines 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.
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.
261
what are outcomes like in hip fracture patients who do not undergo surgery
poor
262
how are minimally or non-displaced intracapsular fractures (e.g. Gardens I/II) treated
These are frequently treated with cannulated hip screws (often 2 or 3).
263
how are Displaced intra-capsular fractures (e.g. Gardens III/IV) treated
These tend to be managed either with a total hip replacement (THR) or a hemi-arthoplasty.
NICE advise that THR is offered to patients who:
- Are able to walk independently out of doors with no more than the use of a stick and
- Are not cognitively impaired and
- Are medically fit for anaesthesia and the procedure
264
how are intertrochantic fractures managed
These may be managed with a dynamic hip screw (DHS) or intra-medullary (IM) nail. DHS are unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.
265
how are
Subtrochanteric fractures
managed
These tend to be managed with an intra-medullary (IM) nail.
266
Post-operatively PT/OT are key due to
helping patients mobilise and get home safely
267
what should be screened for post-hip-op
- delirium
- chest infection
- uti
- op site haematomas/infections (rarer)
- Significant complications like peri-operative cardiac events and DVT/PE
268
how can physio help a patient post-hip-op
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.
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.
269
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.
270
delirium is often
the first sign someone is becoming unwell
271
what are symptoms of delirium
- be easily distracted
- be less aware of where they are or what time it is (disorientation)
- suddenly not be able to do something as well as normal (for example, walking or eating)
- be unable to speak clearly or follow a conversation
- have sudden swings in mood
- have hallucinations – seeing or hearing things, often frightening, that aren’t really there
- 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.
272
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.
273
what are the three types of delirium
hyperactive, hypoactive and mixed
274
do symptoms of delirium stay constant all day
no, they often fluctuate
275
what are symptoms of hyperactive delirium
- seem restless
- be agitated (for example, with more walking about or pacing)
- resist personal care or respond aggressively to it
- seem unusually vigilant.
276
what are symptoms of hypoactive delirium
- withdrawn, feeling lethargic and tired
- drowsy
- unusually sleepy
- unable to stay focused when they’re awake
- stopping eating
- more time in bed
277
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
278
is delirium the same as dementia
no, but similar symptoms
279
what are important differences between delirium and dementia
"- delirium starts suddenly
- delirium's symptoms vary over the day
"
280
which kind of dementia mimicks delirium
Dementia with Lewy bodies.
This type of dementia has many of the same symptoms as delirium (including visual hallucinations) and they can vary a lot over the day.
281
what can be used to test for delirium
4AT test
282
what is the 4AT test
- alertness – whether the person is drowsy or agitated
- awareness – for example, of the current year and where they are
- attention – for example, how well the person is able to name the months of the year backwards from December
- acute change or fluctuating course – whether symptoms started suddenly or are now coming and going.
283
what can cause delirium
"
- pain
- infection
- poor nutrition
- constipation (not pooing) or urinary retention (not peeing)
- dehydration
- low levels of blood oxygen
- a change in medication
- abnormal metabolism (for example, low salt or blood sugar levels)
- an unfamiliar or disorientating environment.
284
who tends to get delirium
older people in hospital
285
what factors put people at higher risk of delirium
- dementia – this is the biggest single risk factor for delirium
- aged over 65
- frailty
- multiple medical conditions
- poor hearing or vision
- taking multiple medications (for example, antipsychotics, benzodiazepines and certain antidepressants)
- having already had delirium in the past.
286
how is delirium treated
- address medical problem(s)
- review medications
- regular eating and drinking
- good nursing care
287
how can you help someone with delirium
- talking calmly to the person in short clear sentences, reassuring them as to where they are and who you are
- supporting the person with familiar objects from home, such as photographs
- making sure that any hearing aids and glasses are clean and working and that the person is wearing them
- setting up a 24-hour clock and calendar that the person can see clearly
- helping the person develop a good sleep routine, including reducing noise and dimming lights at night
- reassuring the person if they have delusions
- supporting the person to be active – to sit up or to get out of bed – as soon as they safely can
- helping the person to eat and drink regularly
- not moving the person unnecessarily – either within and between hospital wards, or into hospital if delirium is being managed at home.
288
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
289
what drugs can be given to treat delirium
low dose of a sedative or an antipsychotic for a few days
290
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
- Delirium is linked to a faster worsening of a person’s mental abilities and function.
- 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.
291
"what kind of forces count as ""low energy"" trauma"
equivalent to a fall from standing height or less
292
what is an osteoporotic fracture
a fragility fracture which has occurred as a consequence of osteoporosis.
293
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"
294
what are risk factors for fragility fractures
295
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
296
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
297
what can compression fractures cause
- Pain and morbidity associated with high doses of analgesia.
- Loss of height.
- Difficulty breathing.
- Loss of mobility.
- Gastrointestinal symptoms.
- Difficulty sleeping.
- Symptoms of depression.
298
what should be considered after all fragility fractures
DXA scan of the lumbar spine and X-rays of the spine
299
what are first line treatments to improve BMD
- cholecalciferol and calcium supplements
- bisphosphonates (alendronic acid)
300
who should be risk assessed for fragility fractures
301
what is denosumab
a treatment for osteoporosis in people intolerant of bisphosphonates.
302
what is the mechanism of action of denusomab
blocks action of RANK-L, a powerful stimulant of osteoclast activity
303
why does low osetrogen cause osteoporosis
in an oestrogen-deficient state, there are more active, longer living osteoclasts, whereas osteoblasts have shorter survival
304
"this shows a![]()
"
displaced intracapsular fracture
305
"this shows a![]()
"
extracapsular fracture
306
"this shows a ![]()
"
non-displaced intracapsular fracture
307
a non-displaced intracapsular fracture can be surgically treated with
"an extramedullary nail![]()
"
308
a displaced intracapsular fracture can be surgically treated with
"hemiarthroplasty![]()
can also be full arthroplasty but more demanding surgery
"
309
an extracapsulary fracture can be treated surgically with
"an intramedullary hip screw![]()
"
310
why are intracapsulary fractures more serious
"risk of avascular necrosis of femoral head as blood supply cut off![]()
"
311
why does age increase risk of osteoporosis with regards to bone reabsorption
"![]()
"
312
what is the medical term for breathlessness
dyspnoea
313
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.
314
what can cause severe breathlessness
respiratory:
pneumonia
asthma
cardiac:
lung and heart disease
heart faliure
315
what is the MRC score system for breathlessness
- No breathlessness.
- Breathless on vigorous exertion - for example, running.
- Breathless walking up slopes.
- Breathless walking at normal pace on the flat; having to stop from time to time.
- Stopping for breath after a few minutes on the level.
- Too breathless to leave the house.
316
what questions should be asked if someone experiences breathlessness (7)
- Did it start suddenly or develop over time? Did anything trigger it?
- How far can you walk? Are you only breathless when you move? Is it worse when you lie down?
- Do you feel ill? Do you have a high temperature (fever), weight loss or a cough? Do you have any pain in your chest?
- Are you coughing up any phlegm (sputum)? What colour is it?
- Have you lost weight, coughed up blood, been in contact with anyone with tuberculosis (TB) or travelled abroad recently?
- Have you recently been bed-bound or on a long flight?
- Do you smoke?
317
what tests may be done on someone with breathlessness
- blood pressure
- peak flow and other lung function tests
- chest X ray
- blood tests (iron, TSH, heart faliure)
318
what can cause short-term breathlessness
respiratory:
asthma
pneumonia
COPD
pulmonary embolism
cardiac:
heart disease
other:
anxiety
medications (beta-blocker, aspirin)
319
what can cause chronic breathlessness
respiratory:
poorly controlled asthma
COPD
cardiac:
heart faliure
arrythmias
other:
anaemia
obesity and poor fitness
320
what can you do if you feel very breathless
- Try not to panic, if possible.
- Call 999/112/911 if severe and sudden with no obvious cause.
- Call your GP urgently otherwise.
- Use your reliever inhaler as instructed if you have asthma.
- Use your oxygen if you have been supplied with it.
321
what can help chronic breathlessness
- 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.
- 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.
- 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.
322
what is the main cause of preventable illness and premature death in the UK
Smoking tobacco
323
when do the benefits of smoking cessation begin
as soon as a person stops smoking
324
why can it be difficult to stop smoking
temporary withdrawal symptoms caused by nicotine dependence
325
what can temporary withdrawl symptoms from tobacco include
physical:
nicotine cravings
sleep disturbances
increased appetite
weight gain
psychological:
irritability
depression
restlessness
poor concentration
light-headedness
326
should e-cigarette smokers be advised to stop smoking
yes
327
what kind of stopping smoking offers the best chance of lasting success
stopping in one step (‘abrupt quitting’)
328
"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
329
what is the most effective approach to smoking cessation
both drug treatment AND psychological support
330
Smokers who wish to stop smoking should be referred to
their local NHS Stop Smoking Services
331
what will local NHS Stop Smoking Services provide
advice, drug treatment, and behavioural support options such as individual counselling or group meetings
332
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
333
what are the 3 effective drug treatments to aid smoking cessation
"Nicotine replacement therapy (NRT), varenicline, and bupropion hydrochloride"
334
what are the most effective drug treatment options for smoking cessation
"Varenicline
a combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)
"
335
what may be prescribed for smoking cessation if first line treatment options are not appropriate
"bupropion hydrochloride or single therapy NRT "
336
should both both varenicline and bupropion hydrochloride be prescribed together
no
337
should varenicline or bupropion hydrochloride be prescribed alongside NRT
not reccomended
338
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
339
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"
340
can e-cigarettes be prescribed or supplied by smoking cessation services
no
341
what should be done if a pregnant person is smoking
advise to stop smoking completely
be informed about the risks to the unborn child, and the harmful effects of exposure to second-hand smoke for both mother and baby
referred to smoking cessation services
342
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.
343
can tobacco smoking affect other medications
yes
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 Interactions of the relevant drug monograph.
344
what is the main reason people smoke
addiction to nicotine
345
where can NRTs be found
pharmacies and some shops
on prescription from a doctor or NHS stop smoking service.
346
what are NRTs avaliable as
- skin patches
- chewing gum
- inhalators (which look like plastic cigarettes)
- tablets, oral strips and lozenges
- nasal and mouth spray
347
how long does NRT treatment usually last
8-12 weeks, before you gradually reduce the dose and eventually stop
348
what are side effects of NRTs
"physical:"
- skin irritation when using patches
- irritation of nose, throat or eyes when using a nasal spray
- difficulty sleeping (insomnia), sometimes with vivid dreams
- an upset stomach
- dizziness
- headaches
349
what is the brand name of varenicline
Champix
350
how does Varenicline work
reduces cravings for nicotine like NRT, but it also blocks the rewarding and reinforcing effects of smoking.
351
is Varenicline avaliable in pharmacies
no, only on prescription
352
how should Varenicline be used
"
It's taken as 1 to 2 tablets a day. You should start taking it a week or 2 before you try to quit.
A course of treatment usually lasts around 12 weeks, but it can be continued for longer if necessary.
"
353
what is bupropion hydrochloride
"
Bupropion (brand name Zyban) is a medicine originally used to treat depression, but it has since been found to help people quit smoking.
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.
"
354
what are the 5 fundamentals of COPD care
"![]()
"
355
when should inhaled therapies be offered for COPD
"![]()
"
356
what should happen regularly with inhaled therapies
review meds
assess inhaler technique
357
what are first line inhaled therapies for COPD
SABA or SAMA to use as needed
358
SABA stands for
short acting beta antagonists
(eg salbutamol)
359
SAMA stands for
short acting muscarinic antagonist (Eg ipratropium bromide)
360
LABA stands for
long acting beta antagonistc (eg formoterol, salmeterol)
361
LAMA stands for
long acting muscarinic antagonists (eg tiotropium, glycopyrrhonium)
362
what are the 2 steps that should be taken to choose the right inhaler for your patients
1. assess inspiratory ability, observe them inhaling using own device if possible
2.patient engagement and inhaler technique
363
what 2 inhalation manoeuvres should be observed
"![]()
"
364
what are the 7 steps for correct inhaler technique
"![]()
Please
Prepare
Every
Meal
In
Big
Containers
"
365
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)
366
how do spacers help
Spacers make it easier to get the right amount of medicine
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.
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.
367
why does using a spacer mean you can use less medicine
"![]()
"
368
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
369
"![]()
these are
"
pMDI inhalers
370
what is a pMDI
pressured metered dose inhaler
371
how is a pMDI inhaler made ready for use
test sprays
372
what are the steps involved in using a pMDI inhaler
- test spray
- shake well
- Sit or stand up straight and slightly tilt your chin up
- Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in
- Put your lips around the mouthpiece of the inhaler to make a tight seal
-Start to breathe in slowly and steadily and at the same time, press the canister on the inhaler once
- Continue to breathe in slowly until your lungs feel full
- 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
-Then breathe out gently, away from your inhaler.
373
"this is a![]()
"
SMI inhaler
374
what does SMI inhaler stand for
soft-mist inhaler
375
what is the priming sequence for a SMI inhaler
Hold your inhaler upright, with the cap closed.
Twist the base in the direction of the arrows until it clicks.
Push up the catch on the side of the inhaler and open the cap.
Point the inhaler towards the floor away from you and press the big grey button.
Close the cap. If you do not see a white cloud, repeat this sequence until you see a cloud.
If you have not used your inhaler for one to three weeks, you will need to repeat this priming sequence once.
If you have not used your inhaler for more than three weeks, you will need to repeat this priming sequence three times in total
376
how should you use a SMI inhaler
Hold the inhaler upright, with the cap closed.
Twist the base in the direction of the arrows until it clicks.
Push up the catch on the side of the inhaler and open the cap. Hold the inhaler horizontally.
Check that there is nothing inside the inhaler mouthpiece.
Sit or stand up straight and slightly tilt your chin up, as it helps the medicine reach your lungs.
Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in.
Put your lips around the mouthpiece of the inhaler to make a tight seal without blocking the two holes on either side.
Start to breathe in slowly and steadily and, at the same time, press the big grey button on the inhaler once.
Continue to breathe in slowly until your lungs feel full.
Take the inhaler out of your mouth and hold your breath for up to 10 seconds, or for as long as you comfortably can.
Then breathe out gently, away from your inhaler. When you have finished, replace the cap on the inhaler.
377
"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.
378
"this is a![]()
"
DPI inhaler
379
what does DPI stand for
dry powder device
380
"this shows a ![]()
"
spacer
381
what are differential diagnoses for shortness of breath on excertion
"![]()
"
382
what are examples of restrictive lung disease
"![]()
"
383
what are examples of obstructive lung disease
"![]()
"
384
what are signs of hyperinflation on CXR
"![]()
"
385
GORD stands for
gastro-oesophageal reflux disease
386
what are the two main symptoms of acid reflux
- heartburn – a burning sensation in the middle of your chest
- an unpleasant sour taste in your mouth, caused by stomach acid
387
what can be four other symptoms of acid reflux, after heartburn and sour tastes
- a cough or hiccups that keep coming back
- a hoarse voice
- bad breath
- bloating and feeling sick
388
when are symptoms of acid reflux generally worse
after eating, when lying down and bending over
389
what can cause acid reflux or make it worse (3)
lifestyle factors: diet (coffee, spicy food), overweight, smoking, stress
co-morbidities: pregnancy, hiatus hernia
drugs: NSAIDs
390
what positive lifestyle changes may stop or reduce heartburn
- smaller, more frequent meals,
- raise your chest and head at night
- weight loss
- reduced stress
391
what should you stop doing if you have heartburn
- trigger foods
- eating 3 to 4 hrs before bed
- smoking/drinking
392
who can help with heartburn other than a GP
pharmacist - prescribe antacids
393
when should you see a GP with heartburn
- lifestyle changes and pharmacy medicines are not helping
- you have heartburn most days for 3 weeks or more
- you have other symptoms, like food getting stuck in your throat, frequently being sick or losing weight for no reason
394
what medications may a GP prescribe for heartburn
PPIs (eg omeprazole or lomeprazole)
395
what further investigations may be carried out for heartburn
"
- tests to find out what's causing your symptoms, such as a gastroscopy (where a thin tube with a camera is passed down your throat)
- an operation on your stomach to stop acid reflux – called a laparoscopic fundoplication
396
what is dyspepsia
"![]()
"
397
"![]()
is described as
"
dyspepsia
398
why is dyspepsia a good term to use
"doesn't imply a cause, so broad differential"
399
when the cause of dyspepsia is oesophageal reflux, what other symptoms may be associated
watering in the mouth
acidic taste in the mouth
400
when the cause of dyspepsia is gastroenteritis, what other symptoms may be associated
nausea, vomiting, diahoerrea
401
what are the most common causes of dyspepsia
- GORD
- functional dyspepsia
- gastritis
- peptic ulcer disease
402
what can be found on endoscopy with functional dyspepsia
- some insignificant gastritis
- nothing
403
what can cause severe gastritis
- infection
- NSAIDs
- alcohol abuse
404
what can gastritis lead to
ulceration
405
what causes oesophagitis
GORD - acid in oesophagus
406
peptic ulcer disease refers to ulcers where
stomach and duodenum
407
what are key symptoms of GORD
- burning pain behind the sternum
- symptoms are worse after eating and lying down
408
what is colicky pain
intermittent, spasmodic pain when a hollow tube contracts to try and remove an obstruction
409
what causes colicky pain
- gallstones
- kidney stones
- intestinal obstruction
410
what may be associated with pancreatitis
steathorrea and DM
411
what is atypical pain for coronary heart disease
dyspepsia
412
what is a serious cause of dyspepsia
upper GI malignancy
413
"what are 'red flag' symptoms"
indicate a potentially serious underlying condition
414
what are 4 red flags for back pain
"![]()
"
415
what are red flags for headaches
"![]()
"
416
where is a good place to identify red flag symptoms
referral guidelines
417
what are NICE guidelines for suspected upper GI cancer referal
"![]()
"
418
an upper abdominal mass consistent with stomach cancer should cause
urgent 2 week cancer referral
419
urgent upper GI endoscopy should be offered
- dysphagia
- 55+, weight loss and one of upper abdo pain, dyspepsia, reflux
420
when should an non-urgent endoscopy be ordered
"- haematesis![]()
"
- 55+, vomiting, low haemoglobin, raised platelets
421
what are red flag signs and symptoms for upper GI cancer
- upper abdo mass
- dysphagia
- weight/appetite loss
422
what medications can affect reflux
"![]()
"
423
what diseases is H pylori associated with
"![]()
"
424
what are FBC cancer red flags
- anaemia
- thrombocyosis
425
why can upper GI tract cancers cause anaemia
- occult blood loss
- cytokines
426
when are stool tests indicated
"![]()
"
427
when are abdominal radiographs useful
"![]()
"
428
what is melaena
dark and offensive smelling stool with digested blood
429
what cells in the stomach produce alkaline mucus
Foveolar cells
430
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
431
how does H pylori reach the mucus layer
chemotaxis and flagella
432
most people with a H pylori infection are
asymptomatic
433
is adhesion to the host by H pylori harmful
no
434
what H pylori toxin causes disruption of the tight junctions between gastric epithelial cells
cagA
435
what H pylori toxin causes gastric cells to undergo apoptosis
vacA
436
what does vacA do
causes gastric cells to undergo apoptosis
437
what does cagA do
causes disruption of the tight junctions between gastric epithelial cells
438
in combination, vacA and cagA disrupt
the lining of the stomach, exposing cells to acid
439
are all strains of H pylori harmful
no
440
what % of the world population have H pylori in their stomach
50%
441
what tests does NICE recommend as a first test for H pylori infection
Carbon-13 urea breath test
stool antigen test
442
what are 4 tests for H pylori
CLO test
stool antigen test
serum antibody test
Carbon-13 urea breath test
443
which tests for H pylori test for Hy pylori proteins
CLO test
stool antigen test
Carbon-13 urea breath test
444
which test for H pylori tests for human proteins
serum antibody test
445
why is the serum antibody test not good for diagnosis
"don't know if infection is current or past"
446
the inside of the stomach is called the
lumen
447
which cells secrete hydrochloric acid
parietal cells
448
which side of a cell faces a lumen
apical side
449
which side of a cell faces a capillary
basolateral side
450
how does hydrogen pass into the gastric lumen from the parietal cell
gastric hydrogen postassium ATPase
451
how do H2 (histamine) receptors increase HCl production
increase numbers of proton pumps in apical membrane
452
PPIs reduce the amount of HCl and also
- anti-urease and anti-ATPase activity
- weak antibacterial activity
453
how do PPIs enhance the effects of antibiotics
decrease the amount of acid making the antibiotic more concentrated
454
how much of acid production is blocked by PPIs
80%
455
what are 3 kinds of drugs which decrease acid in the stomach
H2 antagonists
Proton Pump Inhibitors
Antacids
456
what are 2 PPIs
omeprazole, lanzeprazole
457
what are 2 antacids
magnesium carbonate
aluminium hydroxide
458
what are 2 H2 antagonists
cimetidine
rantidine
459
what is the only test validated by NICE for cure of H pylori
carbon-13 urea breath test
460
why should the carbon-13 breath test be preceded by 2 weeks of no PPIs and 4 weeks of no antibiotics
prevent false negatives
461
what should the carbon-13 urea breath test be preceded by
2 weeks of no PPIs and 4 weeks of no antibiotics
462
fluid that refluxes into the oesophague is usually
acidic
463
when can non-acid reflux occur
- ingested food buffers stomach acid
464
can bile reflux into the oesophagus
yes, rarely if duodenal contents reflux into stomach
465
when will PPIs not help
- functional dyspepsia
- non-acid reflux
- acid production insufficiently depressed
466
what are the 2 kinds of hiatus hernia
sliding and rolling
467
what sex is more at risk of hiatus hernia
males
468
what can cause a hiatus hernia
- widening of diaphragmatic hiatus
- pulling up of stomach (eg oesophageal shortening)
- pushing up of stomach (increased abdo pressure)
469
what is the most common kind of hiatus hernia
sliding
470
"what kind of hiatus hernia is this![]()
"
sliding
471
"what kind of hiatus hernia is this![]()
"
rolling
472
what can be used to treat non-acid reflux
alginate medication like gaviscon
473
how do alginates work
react with stomach contents to form a foamy raft that floats on top of stomahc contents
474
"what phenomenon occurs in Barrett's"
metaplasia
475
"cardiac metaplasia in Barrett's refers to"
cells like the cardia in the stomach
476
what are other names for high grade, non-invasive cells
"![]()
"
477
"Barrett's patients have what every few years"
OGD + biopsy
478
"are people with GORD commonly monitored for Barrett's"
no, unless they have a family history or other risk fatcors
479
what are treatment options for a carcinoma in situ
mucosal resection, radiofrequency ablasion, oesophagectomy
480
how may smoking exacerbate reflux
nicotine may relax lower oesophageal sphincter
481
what medications may cause dyspepsia
calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and nonsteroidal anti-inflammatory drugs [NSAIDs]
482
how is dyspepsia 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
483
Leave a 2-week washout period after proton pump inhibitor (PPI) use before
testing for Helicobacter pylori with a breath test or a stool antigen test
484
what should be offered if dyspepsia does not respond to a PPI
H2 rantidine therapy
485
what is first line treatment for H pylori infection
"offer people who test positive for H pylori a 7-day, twice-daily course of treatment with:
- a PPI and
- amoxicillin and
- either clarithromycin or metronidazole
486
what are biomarkers for diabetic nephropathy
proteinurea
high serum creatinine
487
how many people with diabetes deveelop kideny faliure
1 in 5
488
what is the leading cause of kidney faliure
diabetes
489
if you have diabetes, what should happen at least once a year
urine and blood test for kidney function
490
what are risk factors for chronic kidney disease (8)
are African-Caribbean, Black African and South Asian and over the age of 25
• have a blood relative who has diabetes
• have high blood pressure
• are overweight, especially around your middle
• smoke
• have other complications from diabetes, such as retinopathy
• poor control of blood glucose levels
• have protein in your urine
491
what is the staging system to assess levels of proteinurea
A1, A2, 13
492
A1 means
hardly any protein in your urine
493
if there is hardly any protein in your urine, you will be staged as
A1
494
if there is a small amount of protein in your urine, you will be staged as
A2
495
if there is a large amount of protein in your urine, you will be staged as
A3
496
A2 means
a small amount of protein in your urine
497
A3 means
a large amount of protein in your urine
498
what is eGFR
a measurement of how many millilitres (ml) of blood is cleaned by your kidneys each minute (measured in ml/min).
499
what are the units of eGFR
ml/min
500
what is the normal eGFR in young fit people
80-100ml/min
