GP + general med Flashcards
CVD and public health
What is first-line treatment for hypertension in people over 55?
Calcium channel blockers eg amlodipine (1st line) or nifedipine (2nd line).
What is the difference between dihydropyridines and non-dihydropyridines?
They are both CCBs. Dihydropyridines such as amlodipine and nifedipine are potent vasodilators. They are used more for hypertension. Non-dihydropyridines (verapamil, diltiazem) reduce cardiac conduction and contractility. They are used more for chronic stable angina.
Give two contraindications to using ACE inhibitors and why.
Do not use if RAS or AKI because they reduce the effectiveness of the kidney by inhibiting angiotensin II. (Patients with renal artery stenosis cannot constrict the efferent glomerular arteriole and rely on it being dilated. When ACE reduced AT2 activity, the glomerulus loses its capacity to dilate the efferent arteriole. The resistance and GFR fall due to decreased blood flow.)
In patients with severe RAS, ACEIs reduce glomerular filtration and are likely to cause severe and progressive renal failure.
Give two contraindications to using a thiazide-like diuretic and why.
Do not use in gout or hypokalaemia because they cause increased excretion of water and therefore potassium.
What is the first-line treatment for heart failure with preserved ejection fraction?
Manage comorbidities such as HTN, AF, IHD and diabetes in line with NICE guidance. Then offer cardiac rehabilitation.
What vaccinations should an 8-week-old have?
6-in-1: Diphtheria, tetanus, pertussis, polio, Hib, hep b.
Pneumococcal/ PCV
Rotavirus
Meningococcal B
What vaccinations should a 12-week-old have?
2nd 6-in-1
2nd Rotavirus
What vaccinations should a 16-week-old have?
3rd 6-in-1
2nd pneumococcal
2nd Men B
What vaccinations should a 12-13 month old have?
Hib/Men C
MMR (measles, mumps and rubella)
Pneumococcal booster
Men B booster
What does the 4-in-1 booster contain and when should children get it?
3 years 4 months, as it is the ‘pre school booster’.
Diphtheria, tetanus, pertussis, polio.
Name 5 notifiable diseases.
Encephalitis Meningitis Poliomyelitis Diphtheria Food poisoning Measles Mumps Rubella TB Pertussis Full list available at PHE.
What is the FeverPAIN score?
Score which helps determine how unwell an infant is. Fever during the previous 24 hours Purulence Attend rapidly (Symptom onset <=3 days) Very inflamed tonsils No cough/coryza.
What is safety netting and when should you do it?
If the infant is at a low risk on the traffic light score: responds normally to social cues, no resp/other problems, good circulation and hydration. Safety netting: Tell patient to come back if infant not improving, decrease wet nappies or fever every day for more than 5 days.
Call 999 if they become difficult to rouse, floppy, or develop a non-blanching rash.
Give 5 signs which would indicate intermediate risk of serious illness in a child with fever according to the traffic light tool.
Colour: Pallor reported by carer.
Activity: Not responding normally to social cues, not smiling, hard to wake, decreased activity.
Resp: Nasal flaring, tachypnoea (RR >50 if 6-12 months old or >40 is >12 months old); O2 sats <95% OA, chest crackles.
Circulation: Tachycardia (>160bpm <12 months, >150bpm <24 months, >140bpm <5 yrs), CRT >=3s, dry mucous membranes, poor feeding, decreased urine output.
Other: T >=39 in 3-6 month old rigors, fever >=5 days, swelling of limb or joint, non-weight bearing of a joint.
Give 5 signs from the traffic light tool which would indicate a need to refer an infant on for treatment.
Colour: Pale/mottled/ashen/blue
Activity: No response to social cues, appears ill to a healthcare professional, unrousable or only stays awake for a short time, weak/high-pitched/continuous cry.
Resp: Grunting, tachypnoea (RR >60), moderate/severe chest indrawing.
Circulation: decreased skin turgor
Other: T >=38 in <3 month old, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs/focal seizure.
These all indicate high risk.
What is child health surveillance?
Child health surveillance is the monitoring of the health of children, especially those in at-risk families, between birth and age five.
Give five key opportunities for assessment of children under five years.
Neonatal exam New baby review (around 14 days) 6-8 week examination 1 year health review Health review at 2-2.5 years
What happens at the 6-8 week baby check?
Check for: Congenital heart disease, developmental dysplasia of hip (DDH), congenital cataract, undescended testes
Record: Weight, head circumference, tone, spine examination, palpation of femoral pulses, assess for hernias, whether they are breast-fed.
Also an opportunity for parents to raise any concerns they may have.
What is the ‘red book’ and what does it contain?
The ‘red book’ is the PCHR - personal child health record - which is a national standard health and development record given to parents and carers at a child’s birth. It contains info about immunisations, reducing risk of certain diseases such as SIDS, hearing, eyesight, DDH and milestones.
Give five factors that would indicate an ‘at-risk’ family.
Both parents unemployed
Poor-quality/ overcrowded housing/ homeless
Low income
Neither parent has an educational qualification
Either parents has long-standing limiting illness, disability or infirmity/ addiction/ mental health problem
Give three disadvantages of teenage pregnancy compared to pregnancy over the age of 20.
Increased (3x) risk of postnatal depression
Increased (60%) infant mortality rate
Less likely to finish education
Increased risk of poverty, poor housing
Lower rates of economic activity
Cost to the economy in abortions, delivery and social security payments.
What is Gillick competency?
The capacity of under 16s to consent to treatment without the parents knowledge. A child is Gillick competent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment including the purpose, nature, likely effects and risks, success rate, and availability of other options. This is a decision-by-decision assessment.
What are the Fraser guidelines?
Guidelines which determine a child’s ability to consent to contraceptive or sexual health advice and treatment. Advice can be given if (UPSSI)
- Child has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- Cannot be persuaded to tell parents or allow you to tell them
- Very likely to begin or continue having sex with or without the treatment/advice
- Physical or mental health is likely to suffer without advice/treatment.
- The advice or treatment is in the patient’s best interests.
At what age is a child legally capable of consent to sexual activity?
- Intercourse with any under 13 is always rape. It is still an offence to have sex with an under 16 even if they consent.
At what age is a patient able to take medical decisions independently of their parents?
Between 16-18, depending on if they are considered competent - age is not the only determinant of competence.
What is the definition of health?
Not just absence of disease:
State of complete physical, mental and social wellbeing.
What is the Gini co-efficient?
Statistical representation of the nation’s income distribution among its residents - lower efficient means greater equality amongst people
What are the determinants of health? Give 2 for each category.
Biological: genetics, age, sex, ethnicity, birth weight/premature
Individual lifestyle: smoking, drinking, stress, development (early years), exercise, recreational drugs
Socioeconomic: peer pressure, education, employment, culture, wage, religion, existing disease exposure, access to health care
Environment: air quality, housing, housing stability, water and sanitation, travel, climate
What is epigenetics?
‘the study of how your behaviors and environment can cause changes that affect the way your genes work’ (CDC)
Ie - nurture part and how it affects nature.
The expression of the genome depends on the environment; Lived experience affects human biology.
What is allostasis?
Stability through change. The body’s ability to rise to a challenge.
What is allostatic load?
The price we pay for allostasis - long term overtaxation of our physiological systems leads to impaired health.
Eg, allostasis works to maintain posture and enable physical exertion, overactivation leads to htn, stroke and MI.; allostasis works to respond to pathogens, allostatic load leads to inflammatory disorders.
What is salutogenesis?
Favourable physiological changes secondary to experiences which promote healing and health.
What is primary prevention?
Aims to prevent a disease from becoming established
Aims to reduce or eliminate exposures and behaviours that increase risk of a disease
Can be aimed at individuals or population approach, e.g. immunisations
What is secondary prevention?
Aims to detect early disease and slow down or halt the progress of disease and maximise the chance of a complete recovery
What is tertiary prevention?
Aims to reduce the complications or severity of disease that has already been diagnosed and is symptomatic, by offering appropriate treatments or interventions
What is equality?
Treating everyone the same
What is equity?
Equal opportunity/support proportional to each persons need.
What is horizontal equity?
Equal treatment for equal need. Eg giving 2 people with mild hypertension the same medication that will help them both.
What is vertical equity?
Unequal treatment for unequal need. Eg giving more funding to poorer areas.
What is health improvement? Give an example.
Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities.
What is health protection? Give an example.
Concerned with measures to control infectious disease risks and environmental hazards
What is improving services concerned with? Give an example.
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment, and care. Eg, GP consultations
Give 3 ways domestic abuse impact on health.
Traumatic injury following assault eg miscarriage, fracture
Somatic problems or chronic illness eg headaches, premature delivery
Psychological or psychosocial problems secondary to the abuse eg PTSD, anxiety
Affects child living with domestic abuse - self esteem, education
What is MARAC?
Multi-agency risk assessment conference - meeting with links up to date information about victims needs and risks directly to the provision of appropriate services and responses for the victim, child/ren and perpetrator.
What is the IVDA?
Service which works primary with women who are at the highest risk from domestic abuse in the city, helps them increase their safety by providing advocacy and advice around domestic abuse, safety planning, support through court proceedings and a voice in the MARAC process.
What is health psychology?
Health psychology emphasises the role of psychological factors in the cause, progression and consequences of health and illness.
Aims to put theory into practice by promoting health behaviours and preventing illness.
What are the 3 main categories of health behaviour?
Health behaviour: Behaviour aimed to prevent disease (eg eating healthily)
Illness behaviour: Behaviour aimed to seek remedy (eg going to the doctor)
Sick role behaviour: activity aimed at getting well (eg taking prescribed medications; resting)
What are health damaging behaviours?
Smoking, alcohol abuse, risky sexual behaviour, sun exposure, driving without a seatbelt
What are health promoting behaviours?
Taking exercise, healthy eating, attending health checks, medication compliance, vaccinations.
What is a population level intervention?
Health promotion - the process of enabling people to exert control over the determinants of health, thereby improving health. (PHE)
What is an individual level intervention?
Patient centred approach: care responsive to individual needs.
Give an example of health promotion.
Health promotion/awareness campaigns: change 4 life, 5 a day, stoptober, movember.
Promoting screening and immunisations - cervical smear screening, MMR vaccine
What would be the impacts of primary care intervention to reduce alcohol consumption on the individual, community and population?
Individuals behaviour - less alcohol consumption, individual health outcomes, domestic violence
Local community - local alcohol sales, alcohol-related crime and A+E events
Population level - national alcohol sales and consumption, statistics on alcohol related crime and A+E events, demographic patterns of liver cirrhosis.
[lecture]
What is it called when someone has inaccurate lower perception of risk?
Unrealistic optimism: individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility.
(Weinstein 1983)
Give 5 things that influence an individual’s perception of their risk.
Perceptions of risk influenced by:
-Lack of personal experience with the problem
-Belief that preventable by personal action
-Belief that if not happened by now, its not likely to
-Belief that problem infrequent
+health beliefs, situational rationality, culture variability, socioeconomic factors, stress, age.
Perception of risk impacts on medication adherence, keeping appointments etc.
How would you go about helping individuals to change their health behaviours?
Work with your patients priorities Aim for easy changes over time Set and record goals Plan explicit coping strategies Review progress regularly!!
Why is behaviour change important?
Changing behaviour can impact mortality and morbidity eg adherence to blood pressure medications, exercise -> reduced risk of CVD.
Relatively simple solution - cheaper and easier to change and with less side effects than secondary/tertiary interventions.
What are the main causes of death in smokers?
50% non smoking related
50% smoking related - cancer, COPD, heart disease
Single biggest cause of inequality in death rates between rich and poor in the UK.
Give 3 factors that increase the likelihood of smoking.
Poverty
Unemployment
Unmarried
Male
Give 4 economic impacts of smoking.
Economic - smoke breaks -> loss in productivity; absenteeism, cost of cigarettes, 5% of healthcare costs, cigarette butt cleaning, fires, loss of economic output from death of smokers and passive smokers.
What is the NCSCT and what does it do?
A social enterprise to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services.
Delivers training and assessment programmes
Provides support services for local and national providers
Conducts research into behavioural support for smoking cessation.
In terms of a health needs assessment, what are the definitions of need, demand and supply?
Need = ability to benefit from an intervention
Demand = what people ask for
Supply = what is provided
Example of all overlapping = cancer treatment.
Example of need without demand = vaccination
Example of demand without need = abx for viral infection
What is the difference between a health need and a health care need?
Health need = general need for health, measured using mortality, morbidity, socio-demographic measures
Health care need = specific ability to benefit from an intervention/service.
Health needs assessment covers both
What is a health needs assessment, what is it done for and what are the 3 approaches?
Assessing the felt, expressed, normative and/or comparative need of a population or subgroup (eg manor practice population; a condition (eg COPD), or for an intervention (eg coronary angioplasty). Approaches: Epidemiological Comparative Corporate
What is the name for an individuals perception of variation from normal health?
Felt need
What is the term for an individual seeking help to overcome variation in normal health (demand)?
Expressed need
What is normative need?
Professional defines intervention appropriate for the expressed need.
What is comparative need?
Comparison between severity, range of interventions, and cost.
What is the epidemiological approach to health needs assessment? Give 3 potential limitations.
Epidemiological approach:
Define the problem and size of problem using existing data on incidence and prevalence, morbidity and mortality, life expectancy, services available.
Pros: existing data, can evaluate services by trends over time.
Problems -
Required data may not be available or of adequate quality.
Evidence base may be inadequate
Does not consider FELT NEED
Explain what is meant by the comparative approach to HNA. What is its limitations?
Compares services received by a population (or subgroup) with others - spatial, social (age, gender, class, ethnicity). May examine health status, service provision, service utilisation and health outcomes - mortality, morbidity, QoL, patient satisfaction.
Pros: quick and cheap is data available, indicates whether provision or health is better or worse than comparable areas.
Problems - may not yield what the most appropriate level of provision or utilisation should be, data may not be available, data may be of variable quality, may be difficult to find a comparable population.
What is the corporate approach to HNA and what are the issues with it?
Assessment by politicians, professionals, providers, press, patients - focus groups, public meetings etc. Many stakeholders, decided by ‘the people’
Advantages: based on felt and expressed need, recognises expertise of those ‘on the ground’, takes into account wide range of views
Problems - may be difficult to distinguish need from demand, groups may have VESTED INTERESTS, may be influenced by political agendas, dominant personalities may have undue influence.
What are the theories of causation of health inequalities?
- Psychosocial: stress results in inability to respond efficiently to body’s demands. Impact on blood pressure, cortisol levels and inflammatory and neuro-endocrine response.
- Neo-material: More hierarchal societies are less willing to invest in the provision of public goods. Poorer people - less material goods, lower quality.
- Life-course: combination of the above. Cr
Critical periods - factors possess greater impact at different points in the life course.
Accumulation - hazards and their impacts add up - hard work leads to injuries resulting in disability.
How can you define social class?
A measure of occupation, stratification, social position and access to power and resources.
Quantified using the registrar general’s model (occupation-focussed) or the NS-SEC model.
What is the inverse care law?
The higher the need for medical care within a population, the lower its availability tends to be.
What is incidence?
The number of new cases per unit time - expressed as a % or per eg. 100,000. Can be increased by screening, increasing risk factors.
What is prevalence?
The number of existing cases at a particular point in time. People enter the prevalence pool when they are diagnosed with a condition, and they only leave if they are cured or die.
Give 3 examples of a theory/model of behaviour change.
Health belief model Theory of planned behaviour Transtheoretical model Social norms theory Motivational interviewing Social marketing Nudging Financial incentives
Give 3 examples of transition points where interventions are likely to be more effective.
Starting work
Leaving school
Becoming a parent.
Explain the health belief model of behaviour change. Give 2 limitations/critiques.
Individuals will change if they believe these 4 things:
1. They are susceptible to condition in question
2. That it has serious consequences
3. That taking action reduces susceptibility
4. That benefits of taking action outweigh costs
+ cues to action
Critique of HBM:
Alternative factors may predict health behaviour, such as outcome expectancy, and self efficacy (the person’s belief in their ability to carry out preventative behaviour).
Cognitively based, does not consider emotional influences
What is a cue to action?
Something that triggers behavioural change. Can be internal eg a hangover prompting you to drink less, or external eg a family member having a heart attack prompting you to exercise more.
Explain the theory of planned behaviour model and 2 critiques of it.
Attitudes, subjective norms and perceived behavioural control affect intentions which affect behaviour. Perceived behavioural control also directly influences behaviour. Useful for predicting intentions.
Critique:
47% of intenders fail to act up on their intentions.
No time element involved, no directional causality.
Rational choice model- does not take into account how emotions eg fear or stress may influence rational decision making.
Ignored habits and routines which Simon (1957) referred to as ‘procedural rationality’.
Relies on self-reported behaviour.
How can we bridge the gap between intention and behaviour?
Things that help bridge the intention-behaviour gap:
Anticipated regret - how will you feel if you don’t go to the gym? But don’t shame patients
Implementation intentions - putting medication somewhere where you will remember to take it
Relevance to self
Perceived control - Fisher and Johnson (1996)
Preparatory actions
Explain the transtheoretical model and give 2 criticisms.
= stages of change. 1. Pre-contemplation (no intention of giving up smoking) 2. Contemplation (considering giving up) 3. Preparation 4. Action 5. Maintenance - 6 months onwards. (+relapse at any time)
Acknowledges individual stages of readiness
Critique:
not all behaviours take 6 months to change - time element is arbitrary and not relevant - walking to work vs giving up smoking.
Inconclusive evidence for its efficacy
What is the social norms theory?
Social norms theory is based on educating people about social norms - most people perceive things like drugs use and binge drinking as more common than they actually are. If we can make their perceptions more realistic then we can improve health behaviours. This model may be most appropriate for younger people.
When is motivational interviewing useful?
There is evidence for problem drinkers benefitting from this but not smoking or HIV risk behaviour.
[lecture]
What is social marketing? Give an example.
Social campaign eg stoptober, thisgirlcan, dry january, movember
What is choice architecture? How effective is it?
‘Nudging’ the environment to make the best option the easiest, eg placing fruit next to checkouts instead of sweets.
Problem with this is that there is little evidence to support the view that nudging alone influences health behaviours.
How do you evaluate a health service?
Steps: evaluation, needs assessment, planning, implementation.
Donabedian framework:
1. Structure. what’s there? How many beds/staff?
2. Process - what is done? How many operations or patients seen PER UNIT TIME eg year?
3. Implement output/intervention
4. Outcome - what has improved? the 5 Ds (death, disease, disability (QoL/PROMs), discomfort, dissatisfaction)
How can you measure improved outcomes? What are the issues?
QoL
PROMs - patient reported outcome measures. Eg the Oxford Hip score: ‘during the past 4 weeks, how would you describe the pain you usually have from your hip’
Issues:
Link between health service provided and health outcome may be difficult to establish as many other factors may be involved, eg, case-mix, severity, confounding factors
Time lag between service provided and outcome may be long, eg between healthy eating intervention and incidence of T2DM in middle age
Large sample sizes may be needed to detect statistically significant effects
Data may not be available
There may be issues with data quality. Consider CART: Completeness, Accuracy, Relevance, Timeliness.
What are Maxwell’s dimensions of quality?
Effectiveness Efficiency Equity Acceptability Accessibility Appropriateness
What is malnutrition?
Deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. 2 types:
Undernutrition: Stunting (low height for age), wasting (low weight for height), underweight (low weight for age), micronutrient deficiencies or insufficiencies.
Overweight: obesity and diet-related noncommunicable diseases - CHD, stroke, cancer, diabetes.
Give 3 biological factors affecting nutrition.
Chemistry - levels of gastrin and leptin, thyroid, appetite, genetics, hormonal changes
Give 3 psychological factors affecting nutrition.
Motivation, personal values eg veganism/ ethical eating, mood, sleep (when tired, want carbohydrate).
Give 3 social factors affecting nutrition.
Job - sedentary or active; lifestyle, culture, financial
What is chemical continuity?
The idea that the amniotic fluid is influenced by maternal diet. The in utero environment influences taste exposure to the fetus.
What advice would you give a new mother in terms of providing optimal nutrition for her baby?
Breastfeed ideally for 6 months. Breastfeeding leads to acceptance of novel foods during weaning, less picky eaters in childhood.
Introduce baby to food after 6 months
Good diet and development can still be achieved without breastfeeding. Respect mothers choice either way.
What advice would you give parents of a child who refuses to eat anything other than chips and takes an hour at mealtimes?
Model healthy eating behaviours. Responsive feeding to the child's hunger and fullness. Variety of foods. Avoid pressure to eat Restriction Be authoritative, not authoritarian Don't use food as a reward
What are the issues with dieting?
Better to prevent wt gain.
1. Dieting can lead to eating disorders
2. loss of lean body mass not just fat mass
3. slows metabolic rate and energy expenditure
4. increase subjective sensations of hunger, change in leptin peptide YY.
Fat overshoot - more weight gain due to diet-relapse, especially if you are healthy weight to begin with as your body goes into starvation mode.
What is the externality theory and what are its limitations?
Normal weight individuals responsive to internal homeostatic cues, whereas overweight individuals eat according to external cues eg time of day, dessert as a treat, sensory food cues.
This was introduced in the 1960s (Schachter) and seems to be making a comeback with ‘intuitive eating’.
What is restraint theory?
Theory of why dieting may lead to overeating.
Restrained eating -> effortful process, ignore feelings of hunger. Then they think ‘what the hell’ and overeat. We have natural biological processes to keep food intake within a set range. Dieting decreases your hunger boundary and increases your satiety boundary.
What is goal conflict theory?
Relates to dieting.
Chronic dieters experience conflict between 2 incompatible goals: eating enjoyment and weight control. They are motivated to lose weight but environmental cues prime the goal of food enjoyment.
Successful dieters use food cues in the environment as a weight loss motivational goal.
What are 3 possible explanations of an association?
Chance Causation - Bradford hill criteria; reverse causality Bias - funding, publication bias Confounding Error
Give an example of the high risk approach to prevention, pros and cons.
Identify people at high risk of hypertension and reduce their risk.
☺ individualised, subject motivated, benefit-to-risk ratio is good
☹ costs, temporary
Give an example of the population approach to prevention, pros and cons.
Reduce everyone’s risk, even though this reduction may be low in some people. Seeks to shift the risk factor distribution curve, eg, reducing dietary salt through legislation. This could be a particular subgroup eg elderly/infants, does not necessarily the whole population.
☺ behaviour changes
☹ small benefit-to-risk ratio
What is the prevention paradox?
(Rose 1981): A preventive measure which brings much benefit to the population often offers little to the participating individual. Eg, wearing a seatbelt is unlikely to actually benefit you but about 1 in 500 people it saves their life.
What is the NNT? How is it calculated?
Number needed to treat. - The lower the NNT, the more benefit there is to the treatment.
1/absolute risk reduction
Eg statins: NNT of 40 means that for every 40 people that go on a statin, one person’s risk of disease is reduced.
What is absolute risk reduction? How is it calculated?
Absolute risk difference is the absolute additional risk of an event following an exposure.
= risk in exposed group - risk in unexposed group
i.e. there is a 5% increase in risk in developing cancer if you take the pill
The null value for ARD is that there is no difference - occurs if the confidence interval includes 0.
What is the NNH? How is it calculated?
For a harmful exposure, the number needed to harm is the additional number of individuals who need exposure to the risk in order to have one extra person develop the disease compared to an unexposed group.
= 1/ absolute risk difference.
What is absolute risk? How is it calculated?
Absolute risk = probability that the event will occur. (=P)
= incidence/population
What is relative risk? How is it calculated? When is relative risk used?
Absolute risk in exposed group / absolute risk in the not exposed group
Cant be calculated in case control studies
What is odds? How is odds calculated?
Odds =Probability / (1-probability)
What is odds ratio and how it is calculated? When is odds ratio used?
Odds ratio =
In a case control study this is the odds that a case was exposed/odds that a control was exposed (because you start with the case or control)
In a cohort study this is odds of disease in exposed/odds of disease in not exposed (because you start with exposed or not exposed)
Used in case control studies and in cross-sectional and cohort studies where there isn’t a clear dependent and independent variable
How is addiction defined?
ICD-10: Craving Tolerance Compulsive drug-seeking behaviour Physiological withdrawal state
Give 5 risk factors for problem drinking.
Drinking within the family
Childhood problems with impulse control
Early use of alcohol, nicotine and drugs
Poor coping responses to life events
Depression as a cause not a result of problem drinking
Complex interaction with alcohol and social class - adverse effects of alcohol are exacerbated amongst lower socio economic groups.
What are the most common causes of death due to alcohol?
Accidents and violence Malignancies Cerebrovascular disease Coronary heart disease (nb alcohol causes multisystem disease, physical, psychological and social.)
Ecological studies - what is it, pros and cons?
Retrospective study which looks for association at population level using data already collected. Tells you the risk ratio and rate ratio.
Pros: data already collected.
Cons: Data on exposure and outcome are not linked to the individual so no causality.
Ecological fallacy: trying to draw conclusions about individual level association from group level study
Confounding data not available
Cross-sectional studies - what are they, pros and cons?
Measure frequency of outcome/exposure at one point in time (‘snapshot’) for each participant. Tells you the prevalence.
Pros: Quick, easy, good for surveillance and public health planning.
Cons:
Not for acute outcomes or causality.
Reverse causality, recall bias, non-response bias, information bias, confounding. Does not measure incidence.
Cohort studies - what are they, pros and cons?
(Usually) prospective study in which you find people who have been exposed, then follow up over time to measure incidence of outcome. Tells you incidence rate, ratio, relative and attributable risk.
Pros:
Good for rare exposures, lots of outcomes, dose-response, confounding data collected, temporal sequence. Less risk of selection and recall bias than case-control.
Cons:
Large sample needed, bad for rare outcomes, takes a long time, drop-outs, selection bias, time consuming
Case-control studies - what are they, pros and cons?
Retrospective study where you identify groups on basis of outcome (case) and no outcome (control) and compare for their different exposures. Tells you odds ratio of exposure.
Pros:
Cheap, small sample possible, good for rare outcomes, can study multiple exposures, faster than prospective studies
Cons:
Bias- selection, observer, reported, information, recall, confounders, reverse causality, bad for rare exposure or lots of outcomes, does not tell you incidence or prevalence, can be hard to find controls to match with cases.
Intervention study - what is it, pros and cons?
(Aka RCT?) Prospective study in which participants are allocated an intervention, and their outcome observed. Tells you risk ratio, risk reduction, NNT
Pros:
Reduce bias and confounders, lots of outcomes can be studied, measure incidence, can show causation (potentially)
Cons: expensive, large sample needed, time consuming, drop-outs make follow up difficult, ethical concerns (needs stopping rules), specific inclusion criteria mean less ecological validity.
What is attributable risk and how is it calculated?
Incidence of outcome in exposed - incidence of outcome in unexposed.
What is sensitivity and how is it calculated?
Proportion of people with the disease correctly identified by the screening test.
Sensitivity = true positive/ all with disease
What is specificity and how is it calculated?
Proportion of people without the disease correctly excluded by the screening test.
= true negative/ all without disease
What is positive predictive value and how is it calculated?
Proportion of people who test positive who actually have the disease.
= True positive/all positive test results
Because the numerator will increase with prevalence, as prevalence increases so does PPV if all other factors are the same eg test sensitivity.
What is negative predictive value and how is it calculated?
Proportion of people who test negative who actually don’t have the disease.
= true negative/all negative test results.
NPV will decrease if prevalence increases and vice versa.
What is selection bias?
A type of systematic error in the selection of participants in a study, or allocation of participants to different study groups.
Non-response - those who respond are more likely to have their life together, be young (emails etc) and higher socio-economic group (know academics).
Loss to follow up - are they dropping out because they feel worse/better/move into residential care?
Are the cases different in some way from the controls other than the exposure in question?
What is information bias? Describe the types of information bias.
Measurement - different equipment used to measure outcome in different groups
Observer - researcher knows which participants are cases and which are controls, subconsciously reports or measures them differently.
Recall - Events that happened in the past are not remembered/reported correctly
Reporting - Respondents report inaccurate information because they are embarrassed or feel judged.
What is publication bias?
Bias of wanting to be published so being more likely to make the results interesting or favourable, eg effectiveness of a drug.
What is confounding?
A situation in which the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome.
What is reverse causality?
Association is due to the outcome causing the exposure rather than the exposure causing the outcome.
What are the Bradford-Hill criteria?
Criteria to increase the likelihood of an exposure causing an outcome.
- Strength - stronger association between the exposure and outcome. High RR/OR.
- Consistency - same result observed from various studies and in different geographical settings
- Dose-response - increased risk of outcome with increased exposure
- Temporality - exposure occurs prior to outcome, eg a cohort initially exposed to radiation is subsequently more likely to develop cancer.
- Plausibility of biology
- Reversibility when exposure removed
- Coherence - logical
- Analogy - similarity with other relationships eg similar drug causes similar effects
- Specificity - is the relationship specific to outcome of interest.
Give 3 disadvantages of screening.
- Exposure of well individuals to distressing or harmful diagnostic tests. eg colonoscopy
- Detection and treatment of subclinical disease that would never have caused any problems eg prostate cancer in elderly men
- Preventive interventions that may cause harm to the individual or population eg antibiotic resistance through GBS screening
What are the Wilson and Jungner criteria?
NHS criteria for a screening test.
- Condition:
- important
- detectable early stage
- natural history understood
- primary prevention been done - Screening programme:
- ongoing, decided interval
- cost-effective - Test:
- simple, safe, precise, validated
- acceptable to population
- defined cut-off
- policy on how to manage those with positive result
- clearly set out criteria used to select which mutations are tested for - Treatment:
- effective
- agreed policy on who gets what treatment
- optimised management
What is lead time bias?
When screening identifies an outcome earlier than it would otherwise has been identified - increase in survival time even if screening has no effect on outcome.
What is length time bias?
Bias resulting from differences in length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method. Eg screening with smear detects earlier stage cancer than testing in someone with PV bleeding.
What is atherosclerosis?
Athero = soft, sclerosis = hardening.
Atherosclerosis is a combination of atheromas (fatty deposits in artery walls) and sclerosis (hardening or stiffening of the blood vessel walls).
Affects medium and large arteries
Caused by chronic inflammation and activation of the immune system in the artery wall -> lipid deposition -> fibrous atheromatous plaque develops
Give 2 modifiable and 2 non-modifiable RFs for atherosclerosis.
Non-Modifiable:
Older age
Family history
Male
Modifiable: Smoking Alcohol consumption Poor diet (high sugar and trans-fat and reduced fruit and vegetables and omega 3 consumption) Low exercise Obesity Poor sleep Stress
Other: Diabetes Hypertension Chronic Kidney Disease Inflammatory conditions such as rheumatoid arthritis Atypical Antipsychotic Medications
Give 4 complications of atherosclerosis.
Stiffening of the artery walls -> hypertension and strain on the heart trying to pump blood against resistance
Stenosis -> reduced blood flow -> angina
Plaque rupture -> thrombus in distal vessel -> ischaemia -> MI/stroke/TIA, chronic mesenteric ischemia, peripheral vascular disease
How is cardiovascular disease prevented? What scoring tool may be used?
Advise on diet, exercise and weight loss
Stop smoking
Stop drinking alcohol
Manage co-morbidities (eg diabetes)
PRIMARY prevention:
QRISK3 score: calculates % risk of MI/stroke in next 10 years.
If >10% or CKD or T1DM, start statin 20mg.
Check lipids and LFTs.
SECONDARY prevention: Aspirin Atorvastatin 80mg Atenolol (or other beta blocker) ACEi eg ramipril
What is stable and unstable angina?
A narrowing of the coronary arteries reduces blood flow to the myocardium. During times of high demand such as exercise there is insufficient supply of blood to meet demand.
-> constricting chest pain +/-radiation to jaw or arms.
“stable” = symptoms are always relieved by rest or glyceryl trinitrate (GTN). Not ACS
“unstable” = symptoms come on randomly whilst at rest, part of Acute Coronary Syndrome.
What investigations would you do for angina?
CT angiography = baseline Look for RFs ECG FBC (anaemia) U+E - ACEi/other meds LFTS - statin TFTs HbA1c Lipids
How is angina managed?
Refer to cardiology:
- routine if stable
-urgent if unstable
Educate patient - when to call ambulance etc
Treat medically:
1. Symptom relief: GTN, rest, 5 mins, repeat, 5 mins, ambulance.
2. Symptom prevention - bisoprolol/amlodipine
3. CHD secondary prevention
Procedures/surgery - Aspirin, atorvastatin, ACEi (ramipril), beta blocker.
How is angina managed?
A) medically
B) surgically
Refer to cardiology:
- routine if stable
- urgent if unstable
Educate patient - when to call ambulance etc
Treat medically:
- Symptom relief: GTN, rest, 5 mins, repeat, 5 mins, ambulance.
- Symptom prevention - bisoprolol/amlodipine
- CHD secondary prevention - Aspirin, atorvastatin, ACEi (ramipril), beta blocker.
Procedures/surgery
- PCI: percutaneous coronary intervention = stenting to widen area of stenosis.
- CABG: coronary artery bypass graft. Severe stenosis -> midline sternotomy -> great saphenous vein of the leg used to make a bypass around the area of stenosis.
What is acute coronary syndrome and why does it occur?
ACS:
Unstable angina
STEMI
NSTEMI.
ACS is usually the result of a thrombus from an atherosclerotic plaque blocking a coronary artery. When a thrombus forms in a fast flowing artery it is made up mostly of platelets. This is why anti-platelet medications such as aspirin, clopidogrel and ticagrelor are the mainstay of treatment.
How does ACS present?
Central, constricting chest pain associated with: Nausea and vomiting Sweating and clamminess Feeling of impending doom Shortness of breath Palpitations Pain radiating to jaw or arms Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina. Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”. [ztf]
What would the ECG show in STEMI?
ST segment elevation in leads consistent with an area of ischaemia
New Left Bundle Branch Block also diagnoses a “STEMI”
What would the ECG show in NSTEMI?
ST segment depression in a region
Deep T Wave Inversion
Pathological Q Waves (suggesting a deep infarct – a late sign)
How is ACS dianosed?
When a patient presents with possible ACS symptoms (i.e. chest pain) perform an ECG:
If there is ST elevation or new left bundle branch block the diagnosis is STEMI.
If there is no ST elevation then perform troponin blood tests:
If there are raised troponin levels and/or other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI
If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain
How is ACS managed?
Acute NSTEMI treatment: BATMAN
B – Beta blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative)
M – Morphine titrated to control pain
A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
Give oxygen only if their oxygen saturations are dropping (i.e. <95%).
GRACE score: 6 month risk of death or MI after STEMI.
Secondary prevention: Lifestyle+ Aspirin, Antiplatelet, Atorvastatin, ACEis, Atenolol or other b-blocker, Aldosterone antagonist for those with HF.
Give 5 complications of MI.
Complications of MI (Heart Failure DREAD)
D – Death
R – Rupture of the heart septum or papillary muscles
E – “Edema” (Heart Failure)
A – Arrhythmia and Aneurysm
D – Dressler’s Syndrome
How would you differentiate aortic dissection from MI in someone with central chest pain?
Aortic dissection: Suddenly v painful then gets better. Pain migrates caudally Weak left-sided pulse due to involvement of the subclavian artery HTN is main risk factor
MI:
Builds in intensity
Pain migrates to shoulder
htn is a risk factor but not the biggest one
Which drugs should be given to all patients in acute MI on arrival at hospital?
Bisoprolol 2.5 mg PO, an antiplatelet (clopidogrel) and an anticoagulant (LMWH).
STEMIs presenting >12 hours from onset should be given streptokinase too.
NSTEMIs considered intermediate to high risk should be given tirofiban or eptifibatide (GpIIb/IIIa infusion).
[pts]
What is acute left ventricular failure?
L ventricle unable to adequately move blood through the left side of the heart and out into the body -> backlog of blood that increases the amount of blood stuck in L atrium, pulmonary veins and lungs. This causes pulmonary oedema -> rapid onset SOB, worse lying flat, T1 resp failure (Hypoxia).
Give 4 triggers or acute LVF.
Iatrogenic eg fluids
Sepsis
MI
arrhythmias.
How is LVF managed?
Pour SOD:
Pour away (stop) IV fluids
Sit up
Oxygen
Diuretics
Test for BNP - if negative, HF is excluded. Not specific.
Monitor fluid balance - input and output; U+E bloods, daily body weight.
How does chronic heart failure present?
Breathlessness worsened by exertion
Cough +/- frothy white/pink sputum.
Orthopnoea (the sensation of shortness of breathing when lying flat, relieves by sitting or standing).
Ask them how many pillows they use at night.
Paroxysmal Nocturnal Dyspnoea - waking up at night short of breath, feel like suffocating
Peripheral oedema (swollen ankles)
How is chronic heart failure diagnosed?
Clinical
BNP blood test - NT- pro-BNP
Echocardiogram
ECG
Give 4 causes of chronic heart failure.
Ischemic heart disease
Valvular heart disease (esp aortic stenosis)
Hypertension
Arrhythmias (esp AF)
How is chronic HF managed?
ABAL: ACEi B-blocker Aldosterone antagonist eg spironolactone Loop diuretics Refer if NT-proBNP >2,000 ng/l Surgical treatment in severe stenosis/regurg Measure U+Es regularly.
What is cor pulmonale and what causes it?
R-sided heart failure caused by resp disease, mainly COPD.
Pulmonary htn -> back pressure of blood into R atrium and venous system
How does cor pulmonale present?
Asymptomatic SOB (but will have this anyway with resp disease) Peripheral oedema, syncope, chest pain Pan-systolic murmur Hepatomegaly
How is hypertension diagnosed and defined?
Stage 1: BP >140/90 in clinic or >135/85 ambulatory
Stage 2: >160/100 or >150/95 ambulatory
Stage 3: >180/120
[NICE 2019]
Give 5 causes of hypertension.
- 95% are essential/primary htn.
- secondary causes: ROPE
Renal disease - renal artery stenosis
Obesity
Pregnancy
Endocrine - hyperaldosteronism
What 5 investigations would you go in a patient with newly diagnosed hypertension?
You are assessing for end organ damage - kidney, eye, CVS
Urine albumin:creatinine ratio for proteinuria
dipstick for microscopic haematuria
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities
[NICE]
How is hypertension treated 1st line, 2nd line and 3rd line?
- ACEi (ARB if afro-caribbean or >55)
- CCB eg amlodipine
- thiazide Diuretic
Potassium balance:
Use spironolactone (potassium sparing) if hypokalaemia (can be caused by thiazide diuretic)
However spironolactone and ACEis cause hypERkalaemia - monitor U+Es.
Beta-blocker if K <4.5mmol/l
Treatment targets: <140/90 (<150/90 for over 80 year olds)
- thiazide Diuretic
A patient has red cheeks and a mid-diastolic low-pitched rumbling murmur and loud S1. What could be the diagnosis?
Mitral stenosis. Rumbling noise as blood goes through stiff valve.
MS also causes malar flush and AF.
What causes a pansystolic murmur at the lower left sternal edge, radiating to the axilla?
Mitral regurgitation
Asso with congestive cardiac failure which would cause a 3rd heart sound.
Caused by age, IHD, IE, rheumatic heart disease, ehler-danlos
What causes a high pitched crescendo-decrescendo ejection systolic murmur?
Aortic stenosis.
What can cause a collapsing pulse and an early diastolic soft murmur? Give 2 syndromes which are associated.
Aortic regurgitation.
Collapsing pulse = corrigans pulse. Occurs because blood is pumped out by the ventricles then immediately flows back through the aortic valve back into the ventricles.
Idiopathic age related weakness, CTDs - ehlers danlos syndrome/marfan syndrome
How is AF diagnosed and what will the ECG show?
ECG: absence of P waves reflecting lack or co-ordinated atrial electrical activity,
Irregularly irregular ventricular contractions, narrow QRS tachycardia, HF due to poor filling of the ventricles during diastole, risk of stroke.
What are ventricular ectopics? How are they treated?
Cause of irregularly irregular pulse. Disappear when heart rate gets over a certain threshold eg during exercise.
No treatment required if otherwise healthy.
what is the difference between valvular and non-valvular AF?
Valvular: Moderate or severe mitral stenosis/mechanical valve
Non-valvular = not caused by valve pathology.
Give 5 causes of AF.
SMITH: Sepsis Mitral valve pathology (stenosis or regurg) Ischemic heart disease Thyrotoxicosis Hypertension
How is AF managed?
Rate control: beta-blocker, CCB, digoxin in sedentary people
Rhythm control: only given if reversible cause, new onset, HR, rate control not working. Cardioversion using amiodarone/flecanide or defibrillation under general anaesthetic.
Stroke prevention with anticoagulants - depends on CHADSVASc score.
How would you assess whether a patient with AF should be started on anticoagulation?
CHA2DS2-VASc Mnemonic C – Congestive heart failure H – Hypertension A2 – Age >75 (Scores 2) D – Diabetes S2 – Stroke or TIA previously (Scores 2) V – Vascular disease A – Age 65-74 S – Sex (female)
If score 1, consider anticoag. If >1, offer anticoag.
Which arrhythmias could you see in cardiac arrest and which ones would you use defibrillation for?
Shockable (May use defib) Ventricular tachycardia (VT) Ventricular fibrillation (VF)
Non-shockable:
Pulseless electrical activity - everything else
Asystole - no electrical activity
What are the narrow complex tachycardias and how are they treated?
Narrow QRS:
AF -> b-blocker or diltiazem (CCB)
Atrial flutter - b-blocker
SVT - vagal manoeuvres, adenosine
What are the broad complex tachycardias and how are they treated?
Broad QRS:
VT or unclear - amiodarone infusion
If known SVT with BBB, treat as normal SVT
If irregular may be AF variation, seek expert help
How would you treat bradycardia and heart block?
Stable - observe
Unstable (or risk of systole eg mobitz 2) - atropine
Atropine is antimuscarinic, works by inhibiting PNS. Leads to pupil dilation, urinary retension, dry eyes and constipation.
What could cause a sharp vertical line on an ECG, before the P wave and/or QRS complex?
Pacemaker -
Atrial = line before P wave
Ventricular = line before QRS complex
