H+S Y3 Flashcards
Characteristics of specific food poisoning organisms?
Cryptosporidium - Protozoa, reservoir is GIT, associated with foreign travel. Recreational exposure - water (swimming pools), land (camping) - SEVERE illness in immunocompromised, oocytes resist chlorination
Norovirus - RNA virus, most common cause of infectious gastroenteritis, occurs at any age and in semi-closed environments (hospitals, care homes, schools, cruise ships). Reservoir = man. 24hrs D+V
Clostridium perfringens - part of the normal gut flora. Associated with slow cooking and un-refridgerated storage > spores germinate, toxin producing (like botulinum and diff) > vegetative cells of which cause gastroenteritis. Also causes gas gangrene
Campylobacter - commonest reported cause of infectious intestinal disease. Reservoir = GIT of birds (particularly poultry). Undercooked/raw meat, unpasteurised milk/bird-pecked milk on doorstep. 48-96 hours incubation
Food poisoning investigation?
Preliminary phase - is there an outbreak? confirm diagnosis. What is nature and extent of outbreak?
Immediate steps - who’s ill? how many? case finding - contact those who have been exposed (i.e. set menu at large event). Sx profile? Cause? Proper care arranged? Immediate action (get rid of food)
Collecting data/descriptive epidemiology > time, place, person, no. affected, Sx, common factors, usually use questionnaires (chance of recall bias)
Food Hx - poor recall, structured, lying (if on diet), buffets, snacks
Environmental investigations - environmental health officers visit restaurants and inspect premises, take samples, equipment swabs, and staff not cooking properly
Analytical Epidemiological Studies
used to ID probable cause in absence of lab confirmation.
Point source outbreak = cohort study
Common source = case-control study
Food safety > concerns: food-borne illnesses, nutritional adequacy, environmental contaminants, naturally occurring contaminants, pesticide residues, food additives
Risk factors for chronic liver disease?
Alcohol - prevent with public health campaigns, minimum unit price, taxation, licensing restrictions, sale restrictions (price, placement, promotions)
Obesity - prevent with P.H.C’s, taxation (i.e. sugar tax), sale restrictions (P.P.P), legislature forcing reformulation of foods, community food/exercise regimes, education, healthy snacks at school/work
Viruses - vaccinate (Hep B/Yellow fever), free condoms, screen blood products, decrease needle-sharing, contraception, disposable sharps, licensing/laws for tattoos
Drugs - needle banks, decrease OTC availability (paracetamol, blister packs)
Management of hospital food poisoning outbreaks?
decrease spread with hand washing, bare below elbows, clean equipment, aseptic technique, general ward hygiene, alcohol gel, prohibit potential reservoirs (i.e., cooked food, flowers, etc)
Barrier nursing - use PPE
Side rooms - quarantined bay
Restrict ward access/visiting times - or close to visitors/ new admissions
Lift new cases after 72 hrs symptom free
PHA exclusion from work if ^ risk of spreading = age extremes, immunosuppressed, pregnant women, food industry workers, doubtful hygiene/acceptful levels of hand0washing
Control of infection committee
Infection control officiers
What do you do as a Dr. if you suspect a case?
- report to consultant responsible
- notify local food safety authority
- manage as PTO in hospital
Summary of food poisoning outbreaks?
Incident in which 2+ thought to have a common exposure, experience similar illness or proven infection
General outbreak - members > 1 household/residents of institution are affected
Suspect outbreak - look for common features, identify and isolate source:
> Person - school, workplace, etc.
> Place - been to same event, restaurant
> Time - date/time of onset = can draw curve to show associations and may be able to identify outliers (often key similarity between cases)
Dr’s role of food poisoning:
- treated affected individuals > including how to prevent spread, staying off work until 48hrs Sx-free, fluid replacement
- report to consultant responsible
- inform Food Safety Authority - will isolate and shut down offending source, section 11 of Public health (control of disease) Act 1984 - states you need to notify local authority
Types of food poisoning outbreak?
Common source - people exposed continuously or intermittently to a common source (e.g., infected water)
Point source - sharped upward slope, all cases occurring in one incubation period
Propagation - spread via person-to-person, recurring increases, multiple waves, faecal-oral spread
Summary of Food Safety Act (1990)?
defines food and enforcement authorities and their responsibilities
Food includes - drinks, articles of nutritional value but for human consumption > chewing gum, ingredients
Offences under act:
> sale of food rendered injurious to health, unfit for consumption, not of quality demanded by purchaser
> display of food with label falsely describing food or likely to mislead as to nature of substance/quality
Epidemiology of smoking
In UK 2019, 14.7% of 7.2 million population smoked
M>F, 16.5% men, 13% women
highest proportion 25-34 yr olds
2019 - 74,600 deaths attributable to smoking and 506,100 hospital admissions
NI has highest proportion proportion of smokers in UK, England lowest
Only 2-3% smokers stop each year due to the addictive nicotine
every year >40 they continue smoking, life expectancy decreases by 3 m’s
Never too late to stop smoking
20 mins - HR and BP drop
12 hrs - CO levels drop to normal
2-12 wks - circulation and lung function ^
1-9m - cough and SOB decrease
1 yr - CHD is half of a smoker
5-15 yrs - stroke risk decrease to that of non-smoker
10 yrs - cancer risk half of a smoker
Life expectancy
- quit @ 30 > gain 10 years
- quit @ 40 > gain 9 yrs
- quit @ 50 > gain 6 years
- quit @ 60 > gain 3 yrs
- quit after MI > 50% lower risk of recurrence
Why stop smoking?
^ life expectancy
lower risk of cardio, respiratory and neoplastic disease
lower chance of spontaneous abortions, still birth and growth restriction if stopped in pregnancy
reduces risk of SIDS and illnesses of children
saves money
Smoking cessation
Motivational interviewing - facilitated by any healthcare professional and plants seed to help seeking
Stop smoking groups - sessions run by HCP, giving advice and group sharing own tips.
One to one counselling - involve GP/murse explaining benefits, leaflets + helplines, or regular sessions with smoking cessation counsellor or group therapy
NRT - double chances of stopping, less addictive, doesn’t cause ca, available via prescription or OTC as gum, patches, tablets, spray, lozenges, inhalers
Bupropion - reduces cravings and helps withdrawal Sx
Varenicline - blocks nicotinic receptor so smoking doesn’t produce desired effect
Lung cancer epidemiology
most common cause of cancer death in UK, 22% of all cancer deaths
third most common cancer in the UK (1 breast 2 prostate 3 lung 4 bowel)
third most common cause of death in the UK after IHD and CVD
mortality decreasing in men, increasing in women
more common in men, 1.2:1, M:F
peak incidence 85-89
smoking directly related
other RFs - dust, coal, tar, radiation, radon, asbestos, FHx
Stop smoking campaigns
education in school and to pt’s
tobacco TV and printed adverts are banned
^ taxes to deter
adverts on packs about risks
age restrictions
smoking banned in public enclosed spaces
mass media campaigns about benefits of stopping
wider access to smoking cessation services
whilst relatively ineffective, smoking cessation is cost effective, even brief <3 mins in consultation has x2 better rate than simply asking
Smoking cessation in unwilling pt
5 Rs
Relevance - why important, 2nd hand exposure, health finances
Risks - remind of -ve consequences
Rewards - benefits of quitting, financial, regaining taste, decrease mortality
Roadblocks - identify what’s stopping them, withdrawal Sx, weight gain etc
Repetition - every time you see them
Smoking cessation in willing pt
5 As
Ask to quit at every visit
Advise to quit
Assess willingness to quit
Assist quitting > pharmacotherapy and counselling (gold standard)
Arrange follow up
Occupational lung disease implications for pt:
- employers must make work safe and create a work environment and practices that will not cause further problems
1 - may need to change job - continual exposure can cause permanent damage
2 - may be entitled to benefits and/or compensation (industrial injuries disablement benefit if a recognised disease)
3 - compensation can include before/after death = these conditions have a poor prognosis > British Lung Foundation can help with this as well as the Department for Work and Pensions
Causes of occupational lung disease
Asbestos - roofers/plumbers
Coal - miners
Aspergillus - malt worker, farmer
Cigarette smoke - bar work
Radiation - radiographer
Silica - metal mining, pottery manufacture
Arsenic - paint factory
Role of Dr in occupational lung disease
diagnosing/testifying in court
if diagnose rare condition, or cluster of more common, notify Public Health authority
reporting Injuries, Diseases or Dangerous outcomes regulations (RIDOR) = legal requirement for incident reporting
Preventing occupational lung disease
HSE (health and safety executive) has a working group on Action to Control Chemicals (WATCH)
WATCH to consider evidence on occupational exposure and health effects of substances, this includes:
1 - whether max exposure limit (MEL) or occupational exposure standard (OES) would be appropriate and setting limits where indicated
2 - cases recommend measures based on a couple of cases, including looking at long term, consequences
3 - it is probably impossible to prevent all industrial dust disease, but they can certainly be reduced by following appropriate safety precautions, including adequate ventilation, keeping down dust levels in work place, and the wearing of facemarks. In addition ca have limited exposure to a pathogen and appropriate cleaning of work areas
When is post-mortem a legal requirement?
1 - sudden death 2 - unknown cause of death 3 - unnatural death - accident/suicide/suspicious 4 - death from industrial disease 5 - death from negligence 6 - death during surgery/anaesthesia 7 - death within 24hrs admission 8 - not seen by a Dr for 14 days 9 - any pt. detained under MHA
SAD SUN DUI
Why are post-mortem beneficial?
gain deeper insight into pathological processes - improve prognoses for future pt’s
learn how to prevent patients death in future > teaching and medical research
further understand long term effects of drug therapy
explore how certain diseases progress or how they can be stopped from progressing
study and monitor levels of chemical and radioactive elements absorbed from the environment
Role of HM Coroner
investigate and ascertain causes of deaths occurring in suspicious circumstances - body can’t be released under coroner satisfied with cause of death
Consent to post-mortem
Coroner’s post mortem/inquest does not need consent (i.e. if there’s criminal investigation)
Hospital post-mortems do need consent
consent may otherwise be from - deceased before died, a nominated representative, a qualifying relationship (spouse/partner, parent/child, brother/sister)
Impacts of obesity
social - low self esteem and poor body image, bullied, social outcast, not suitable for certain jobs, hard to find clothes, stigma, exclusion from certain activities, can’t have surgeries/IVF
economic - ^ health resources, new equipment to account for ^ in society, reduced productivity
Causes of weight gain in Western society
high saturated fat diet - too expensive to eat healthy (School meals not healthy), time constraints on eating healthy, social expectation of large portions and unacceptable to be hungry, unhealthy options advertised in shops, labelling systems don’t highlight what food is healthier
sedentary lifestyle - less active jobs, less commuting to work due to transport, more lifts/elevators so less walking, not safe on roads for cyclists
less exercise - most passive leisure activities, lack of affordable community venues for exercise, lack of attractive outdoor areas for walking/playing with kids
lack of education - how to budget, what is important to eat, why it’s important, poor provision of physical activity in and out of curriculum, poor management of bullying/fat teasing
role of genetics/ethnicity - black/hispanic more susceptible that caucasian
Diabetes Prevention programme trial (DPPT)
risk of conversion of IGT and DM is 5% annually and 50% lifetime risk - WHO IGT criteria - impaired fasting = 6.1-7.9 mol/L, impaired 2hr test = 7.8-11 mol/L
association with ^ weight and risk of developing diabetes
early aggressive lifestyle interventions (58% decrease) in obese patient with IGT was more effective at preventing onset of DM compared to placebo or metformin (31% decrease)
trial highlighted importance of lifestyle interventions in preventing DM = better than pharmacology
Diabetes control and complications trial (DCCT)
compared standard and intensive insulin therapy in large prospective controlled trial
epidemiology of diabetes interventions and complications (EDIC) was follow up study on 90% participants, looking at CVD and effects of intensive control of QoL and cost. Helped establish metabolic goal of diabetes care and the means to achieve these goals
conclusions - intensive Tx aiming for glycemic control like non-DM, decrease development and progression of DM complication, intensive Tx decreases measures of atherosclerosis and probably CVD over time, intensive Tx most effective when implemented early in course of DM, if delayed complications are harder to slow
Diabetes and Impaired Glucose Tolerance (IGT)
long period of IGT that precedes development of DM
screening tests can identify who are at risk of progressing to DM and hence use effective interventions and address modifiable RFs = obesity and body fat distribution, physical inactivity, elevated fasting and 2hr glucose levels
Complications of DM
microvascular - retinoapthy, nephropathy, neuropathy
microvascular - peripheral vascular, cardio, cerebrovascular
others - impaired wound healing and ^ susceptibility to infection
Screening programmes for DM
for retinopathy + podiatry
clinics monitor renal function, HbA1c, lipids, BP
Diabetes Prevention Programme
primary goal - prevent or delay development of T2DM in patient with IGT
secondary goal - reduce CVD events, reduce CVD RF’s, reduce atherosclerosis
findings
- intensive lifestyle modification more effective than met form at decreasing DM development
Psychological impact of DM
grief - loss fo freedom (dietary), change to self image, can’t escape condition (lifelong, can lead to depression)
denial - interferes w/ pt self management, significant issue in teens with T1DM = don’t comply as rebelling
stress - a lot of responsibility, especially for young patients, needs trade off of short vs long term benefits, may cause family conflict, burden on family, anxiety for future if have hypo
can neglect insulin if eating disorder
social perception > stigma (T2DM - obesity, amputation), invisible disease so less empathy, embarrassment if have hypo
hormone deficiency can manifest as lethargy and malaise = decreased social mobility/intercation, increase in social withdrawal
Independent Assessor in organ donation
all liver donors and organ recipients are required to see an independent assessor who is trained and accredited by Human Tissues Act (HTA). Will submit report to Human Tissue Authority. they are distinct to the acting health care team
Role:
- interview both parties, together and individually to establish: nature of relationship, not being forced, no incentive, donor has capacity
conditions met to be living donor - should be competent and >18, risk to donor is low, decision is fully informed, decision voluntary and not coerced or incentivized, transplant must have good chance of successful outcome
Impact of dialysis on pt
disruption to life = travel time and cost (Takes up large periods of day (lead to isolation/depression), limitation of travel due to Tx
often pt still heavily symptomatic as only 10% renal function - doesn’t replace endocrine function
have restrictions on fluid and salt intake
quality of life vs. quantity
uncertainty of waiting for transplant - pt may also give failed transplant
Outline Transplants in the UK
governed by human tissue authority (HTA)
Human tissue act 2004 - act regulates the removal, storage and use of human tissues for following reasons: research, transplantation, education
requires consent for the above - either either before death (opt in) or after death from family
includes - allowed to take minimum steps to preserve organs of deceased person, whilst steps taken to determine persons wishes, or to obtain consent from someone in qualifying relationship
However - is offence to remove material form dead body w/o consent (other than autospy reasons), organs/tissues should be stored in line w/ current good practice on: security, traceability, and H+S
The act makes it unlawful to treat as ‘waste’, any relevant material which has come from a person who was: receiving medical Tx, undergoing diagnostic testing or participating in research
Summary of organ donation in UK
Currently in UK for receiving organs: resources scarce > decisions have to be made on opportunity cost = loss of alternatives, the one option is taken
With relevance to transplantation this means this means some pt’s are to be denied transplant over others who would benefit more = more cost effective
Currently - DBD (donation after brainstem death) allocated via national allocation scheme (NHSBT)
DCG (donation after coronary death) = allocated regionally - one kidney always offered preferentially to local transport centre
Currently based on points system:
Tiers A+B prioritised first, then goes to below points based system
- points for compatibility (HLA) and age = favours younger, well matched individuals
- time on transplant list
- age difference between donor/recipient = want to be close
- location = favour closer pt., social factors also considered > alcohol abstinence in pt. needing liver transplant = likelihood of success
Tier A - 000 mismatched, paed’s pt’s highly sensitised or HLA-DR homozygous
Tier B - 000 mismatched paed’s pt’s, others
Tier C - 000 mismatched adult pt’s, highly sensitised or HLA-DR
Tier D - 000 mismatched adult pt’s, favourably matched paed’s pt’s
Tier E - all other eligible pt’s
Donor scheme based on altruism
Summary of opt-out system
20 May 2020
as average wait for donor organ is 3 yrs
excluded groups - under 18, lack capacity, visitors to England and those not living here voluntarily, people living in England for less than 12m’s before death
For
- will include those can’t be bothered to volunteer
- reduces pressure on grieving family
- still allows to deny permission
- cost effectiveness (i.e., vs dialysis)
- supply currently doesn’t match demand
- QoL better w/ transplant that dialysis
Autonomy
- shouldn’t assume pt. choices > autonomy
- human rights when dead + right not to donate
- decisions could be based on different groups
- risking state becoming authoritative - removing pt. freedom
- issue is stigma w/ not opting out
Should age be considered in transplant process?
- Tx of elderly expensive (burden of cost not related to age per se, more costs of illnesses/incapacity in final years, but even so, isn’t this price with paying for equal society? > devalues elderly, causing inequality between young + old
- fair innings argument - they’ve had their time and young people haven’t BUT what is a full life? have they had QoL? why does length bear an impact if outcomes better for elderly?
- elderly less likely to respond to Tx - but age alone is not a good predictor of responsiveness to Tx or prognosis, denying Tx based on age is discrimination (illegal under Equality Act 2010)
> direct discrimination - 1 person being treated in less favourable that another in comparable situation
> indirect discrimination - seemingly neutral provision has harmful repercussions on a person
> GMC - you must not unfairly discriminate
Arguments for and against the blood market?
Against
- represses altruism
- erodes sense of community
- redistribution supply from poor to rich (^ infection rates, decreases quality)
- pt. may make unwise decision due to financial incentive
- sanctions profits in health care - may result like US where poor have less access to healthcare
For
- everyone has the right to choose what to do with their body
- increases supply
- financial rewards may be exemption from any future payment
- not different from any other traceable good
Argument re: market for organs
Improves QoL of more pt
Cheaper than expensive mechanical Tx and long term complications from not treating
suggestion - use opt out instead
paying for transplants have same -ve’s as blood market
Strengths and limitations of ICD-10/DSM
Strengths
- standardisation of diagnostic criteria
- allows epidemiological studies, geographical comparisons of prevalence and incidence
- alphanumerical format - allows quick referral and easy addition to categories
Limitation
- 2 different criteria sets, so who uses what
- Schizophrenia diagnosis relies on many psychotic Sx, which are a common final pathway in other disease
- groups commonly co-existing Sx pattern, without understanding of underlying cause/nature
What is advocacy?
everyone detained under MHA legally entitled to a professional MH advocate = statutory advocate
independent MH advocate (IMHA) or an IM capacity advocate (IMCA)
otherwise can be professional, family, friend, carer or you can be your own (self advocacy)
helps ensure the patient’s opinions and ideas are articulated clearly and taken seriously
role of advocate:
- listen to views and concerns
- help explore options/rights (without advising)
- give info to help informed decision making
- help you contact people, or contact on your bhealf
- accompany and support you in meetings/ appointments
Epidemiology of DSH and suicide
DSH F>M
suicide M>F
previous attempts ^ risk of success by x40
rates ^ fastest in western countries
common - evenings, weekends, spring and autumn
divorced/widowed
SES 1+5
unemployed
uni students
Dr, lawyer, farmer, police
> 90% have psychiatric illness
recent loss
chronic illness
Role of MH teams in management of depression
MDT approach
GP - diagnosis and community management
CPN - talk through problems, offer advice + support, give meds, monitor SFx
psychiatrists - diagnosis and primary assessment > prescribe medication
OT - teach skills, help ^ confidence and independence
social workers - money, housing, childcare
pharmacists - dispensing meds, advice to Dr’s and nurses
key workers - manage cases
Health promotion strategy for alcohol and drug misuse
Education - less effective, PSHE in schools, TV/radio ads, provision of info in GPs, online. or 2’ or 3’ care centres
Policy - effective - minimum unit pricing, taxation, restrict availability, restrictions on promotions and placement on shop floor, stricter licensing laws, restrict advertising, getting ‘big money’ out of policitics
Mass medical campaign - less effective - Drink Aware - still encourages drinking, just responsible drinking
Support and info - Frank
Health care worker role - ID and brief advice , CAGE q’s, hospital alcohol health workers, hospital admission/ED is teachable moment, can implement screening, detox, brief intervention, referral and support other staff
specialist Tx - CBT, ^ nutritional status
Community, residential and nursing home support for pt’s suffering from psychiatric disorders in old age
Community support - CPN and care assistants visits so people can stay in own home, helps relatives, can be expensive
- day centres - available for socialising, provide food, place of contact with MH practitioners
- respite care - give caters a break
Sheltered housing - semi-independent living, in apartment complexes with a warden, offer group activities and HC worker visits
Residential home - 24 hour staffing, usually with HCPs who help with ADLs and provide meals, not suitable for those with high level of medical care needs
Nursing home - highly dependent, residents who are unable to care for themselves, regular Dr. visits and ^ nursing stage compared to other styles
Psychiatic inpatient unit - elderly with psychiatric conditions
Effects of caring for someone with dementia
Looks after someone unpaid (formal/unformal), women>men, 50-64 has highest proportion of carers, highest proportion in more economically deprived areas
Initial impact - emotional initial response (fear, angry, grief), determined by understanding, pt. reaction, nature of relationship
Longterm impact - spouse = relationship skewed as one partner contributes less (practically, companion, emotionally, sexually, financially), child (role reversal, conflict with family members, can reduce child’s opportunities), generally (isolation, less time with F+F, stressful, emotionally straining, anticipatory grief
Health effects - chronic stress, poor sleep, burnout, no breaks, physical effects of doing everything, less care for own health
What support is available for those caring with dementia?
Policy + legislation:
(carers (recognition and services) act 1995)
Carers has right to assessment of own needs, despite refusal by recipient of care - carers must be aware of this
carer’s special grant - funding for respite/short breaks
assessments must consider carer’s wishes, i.e., employment, education, leisure etc. - wellbeing not just health
Employment support:
Work and families act 2006 > carers of adults can request flexible hours
Emotional support
Counselling, support groups
Financial support
- carer’s allowance
- bedroom tax
- welfare reform act 2012
Practical support
- moving + handling training
- education - S+S, natural Hx,
- respite
- social services/community nursing - cleaning, personal care
Impact of MH in primary care
MH condition reduces QoL
Interfere w/ other health conditions - can be caused and cause co-morbidities, complicate Tx
Misdiagnosed/not-detected
Large economic burden - medication and lost working days
Organisation of UK MH services
most MH services require GP referral
95% of MH managed by GPs
Coordinated system @ local level
Build around individual’s needs and views
Rapidly accessible
Community based (formerly psychiatrist @ centre w/ long inpatient stay)
Reasons for referral to 2’ care:
- moderate-severe mental illness > BPD, severe depression, schizophrenia
- pt’s at serious risk to themselves or others
- uncertainty re: diagnosis
- poor response to standard Tx/specialist Tx required
Not including:
- IAPT (improving access to psychological therapies)
- pt’s who have drug and alcohol problems
- community mental health team (systematic assessment, plan to address needs, allocation of care coordinator)
Impact of race/ethnicity + age on psychoses?
Schizophrenia = ^ young men>women, BME groups ^, ^ in socially disadvantaged groups
Affective psychoses = M+F, no evidence for geographical/neighbourhood effect on incidence, rest same as schizophrenia
Points of care in MH services
outpatient clinics
day hospitals - non-residential units, require pt. to have supportive home environment to return to can also be used to slowly discharge pt. back to community
assertive outreach teams - effectively high level CMHTs for challenging patient (pose real threat of harm + does not want to engage with MH services)
in-patient units > admitted when high risk (to self or others), grossly disturbed behaviour, or period of assessment needed (diagnosis/ Tx efficacy) for severe psychiatric disorder
early intervention services - works with young people over the age of 14 (<35) to deal with first episode of psychoses as evidence earlier Tx improves prognosis - have more intensive input
crisis resolution + home team - team that can support you at home during a MH crisis (suicidal ideations, mania, psychotic episodes, severe panic attacks) - available 24/7, can provide intensive + flexible homes support to prevent admission
