Metabolic and Endocrine Flashcards
what is food poisoining?
- Gastroenteritis with infectious cause with presumed source being from food.
- Time from eating to symptom onset = incubation period – can inform what organism/toxin it is.
- i.e. toxins/heavy metal v.v. quick onset of D+/-V, viruses + bact. slower
what infections are the biggest burden?
- Campylobacter
- Rotavirus (mainly U5s, but vaccine now)
- C.diff
- Norovirus (short-lived so underreported)
- C. Diff, MRSA + Norwalk important nosocomial
what are the characteristics of salmonella?
G-ve, incubation 12-72hrs, contaminated food mainly of animal origin, or faecal from infected person. Reservoir is mainly eggs. Clinically: cause enteric fever (typhoid/paratyphoid fever) + Enterocolitis. Incidence ↓ through PH measures – peak in late summer
what are the characteristics of e.coli?
Various types, can cause renal failure in children, haemolytic uraemia, O157 H7 (enterohaemorrhagic) v. dangerous. Reservoir in cattle, can be through food/animal contact. Incidence steady. 12-48hrs
what are the characteristics of Bacillus cereus?
1-6hrs, cooked rice.
what are the characteristics of S.aureus
G+ve cocci. Previously cooked food contaminated with skin/nasal flora. Produces toxin → rapid incubation period (2-4hrs)
what are the characteristics of cryptosporidium?
Protozoa, reservoir is GIT. Associated with foreign travel. Recreational exposure – water (swimming pools), land (camping) – SEVERE illness in immunocompromised, oocysts resist chlorination.
what are the characteristics of norovirus?
RNA virus, most common cause of infectious gastroenteritis, occurs at any age and in semi-closed environments (hosps, care homes, schools and cruise ships). Reservoir = man. 24hrs D+V.
what are the characteristics of clostridium perfringens?
Part of normal gut flora. Associated with slow cooling + un-refrigerated storage – spores germinate, toxin producing (like botulinum + diff)vegetative cells, ingestion of which gastroenteritis. Also causes gas gangrene.
what are the characteristics of 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
what is the preliminary phase of food poisoning outbreak?
Is there an outbreak? Confirm diagnosis. What is nature + extent of the outbreak?
what are immediate steps t take during a food poisoning outbreak?
Who’s ill? How many? Case finding – contact those who have also been exposed, i.e. set menu at large events. Symptom profile? Cause? Proper care arranged? Immediate action (get rid of food).
describe data collection/descriptive epidemiology during a food poisoning outbreak?
Time, person, place, no. affected, symptoms, common factors, usually use questionnaires (chance of recall bias).
describe environmental investigation
Environmental health officers visit restaurants + inspect premises, take samples, equipment swabs, and staff not cooking properly.
what are potential causes of food safety concern?
food-borne illnesses, nutritional adequacy, environmental contaminants, naturally occurring contaminants, pesticide residues, food additives
describe the role of analytical epidemiological studies in food poisoning outbreak?
Used to ID probable cause in absence of lab confirmation. Point source outbreak = cohort study, common source outbreak = case-control study.
what is the role of the public health act in preventing food poisoning outbreeaks?
allows exclusion from work of people that pose an increase risk of spreading GIT
- Persons with doubtful personal hygiene/unsatisfactory toilet hand-washing
- Children in nursery or pre-school groups
- People whose work involves prep
- H&S care staff who have contact with highly susceptible persons (extremes of age, pregnancy, immunosuppressed)
what is the purpose of UK food law?
Based on 1° objectives of: High level of protection of human life + health, protection of consumers’ interests, fair practices in food trade.
describe the food safety act 1990?
Defines food + enforcement authorities + their responsibilities. ‘Food’ includes: drink, articles of no nutritional value but for human consumption, chewing gum, ingredients.
•Offenses 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.
what should a doctor do if they suspect food poisoning?
- Report to consultant responsible
- Notify local food safety authority
- Manage as below if in hospital…
describe the management of hospital outbreaks of food poisoning?
- ↓with handwashing, bare below elbows, clean equipment, aseptic techniques, general ward hygiene, alcohol gel, prohibit potential reservoirs i.e. cooked food, flowers etc.
- BARRIER NURSING (use PPE – gloves, gowns) • Side rooms – quarantined bay
- Restrict ward access/visiting times – or CLOSE to visitors + new admissions
- Lift new cases after 72hrs symptom free
what are the aims of clinical guidelines?
- Improve quality of healthcare - ↑ chance of better outcomes
- Provide recommendations for care, based on best evidence
- Used to develop standards against which healthcare professionals should be assessed
- Used in education of professionals
- Help pts make informed decisions
- Improve communication between patient + HC professional
how do you assess if a guideline is decent?
- scope and purpose
- stakeholder involvement
- rigour or development
- clarity of presentation
- applicability
- editorial independence
what is scope and purpose?
described overall objective? Described specific health questions? Population
what is stakeholder involvement?
target users defined? Views/preferences of target population sought?
what is rigour of development?
Systematic search for evidence? Selection criteria? Appraisal of evidence? Methodology for formulation of recommendations? External review? Updating procedure?
what is clarity of presentation?
specific/unambiguous? Clearly presented options? Key recommendations easily ID’d.
what is applicability?
Advice/tools on how to put into practice? Facilitators/barriers described? Resource implications? Monitoring/auditing criteria?
what is editorial independence?
funding body did not influence content? Recorded competing interests of committee involved in development?
what are the barriers to uptake of evidence due to?
characteristics of the adopters
organisation and environment
what characteristics of adopters can be a barrier to evidence uptake?
- Knowledge -> lack of awareness of new, or how current practise is inappropriate
- Attitudes ->Doubts over credibility of source, perceived pt resistance
- Skills + abilities ->overreliance on trusted/convenient sources, confidence in skill set
what issues with the organisation and environment can be a barrier to uptake of evidence?
- Limitations + constraints-> time, resources
- Organisational culture ->Behaviour, pressure to act/follow certain rules
- Social influence -> team norms, influential peers
how can you encourage people to adopt changes to guidance?
quality improvement
how can quality improvement encourage people to adopt guidance?
-how to apply the findings. Interactive + iterative, engage participants across organisational levels, meetings, remove barriers, provide knowledge + resources to implement, foster environment where improvement + innovation = normal! This will improve performance, professional development + pt outcomes.
•Multifaceted approach, actively disseminating info + ↓ barriers is BEST WAY TO CHANGE. Also pt initiatives (involving them from start) gives highest rate of change.
•Audits, pressuring poor performers/praising high performers/league tables DOESN’T WORK.
what are the aims of audit?
- Clinical education
- Encourages teamwork
- Improve service/care
- Gain financial incentives
- Fulfil contractual obligation
what are the steps of audit?
- Set STANDARDS – NICE/local guidelines
- Measure CURRENT performance
- COMPARE vs. standards – how are we doing?
- ID barriers/steps to improve – how can we/what’s stopping us get better?
- Make CHANGES – implement plan
- RE-AUDIT – did the plan work?!
what are the strengths of audit as an approach to QI?
- Encourages teamwork
- Can lead to ↑patient outcomes
- May get financial reward
- Emphasises best practice
what are the limitations of audit as approach to QI?
- Data is merely a ‘Snapshot’ of performance
- Lack of generalisability
- Accuracy of data collection
- Sample size – adequate?
- Short timescale – change ->long term benefits/harms?
- May -> RUSHED ‘quick fix’
- Relies on staff to actually implement it!
what are the risk factors for chronic liver disease?
alcohol
obesity
viruses
drugs
how can the following risk factor for chronic liver disease be prevented;
Alcohol
Public health campaigns, minimum unit price, taxation, licensing restrictions, sale restrictions (price, placement, promotions)
how can the following risk factor for chronic liver disease be prevented;
obesity
Public health campaigns, taxation (i.e. sugar tax), sale restrictions (price, placement, promotions), legislature forcing reformulation of foods, community food/exercise regimes, EDUCATION, provide healthy snacks at school/work
how can the following risk factor for chronic liver disease be prevented;
viruses
Vaccinate (Hep B/yellow fever), screen blood products, ↓needle-sharing, contraception, disposable instruments/sharps, licensing + procedural laws for tattooing etc.
how can the following risk factor for chronic liver disease be prevented;
drugs
Needle banks, ↓OTC availability (paracetamol, blister packs
how might the priorities for the prevention of chronic liver disease differ internationally?
- prevalence of disease • Resources available • Political support for intervention
- population-attributable risk for different factors (i.e. in UK PAR for obesity»_space;> in W. Africa – where yellow fever ↑)
describe the provision of diabetic services?
GP (BP, lipid + glycaemic control, annual review), diabetes specialist nurse clinics, HCAs (BP, bloods, weight), podiatrist/chiropadist, ophthalmologists (diabetic eye disease, renal physicians, gastroenterology (if gastroparesis), endocrinologist (may advise in complex cases), vascular medics, charities, district nurses (widens access), dieticians!! (advise on correct diet in group classes)
why do diabetic services differ?
funding
prevalence
staffing/resources
what are the different types of diabetic services?
- Nurse-led/community – patient centred and allows continuity of care, though may not be able to advise on complex cases
- GP led – can advise complex cases, adjust meds BUT ↓likely to see same GP, takes up time which may not be necessary for each review
what is the social impact of pituitary, adrenal and thyroid disease?
- Constant burden of lifelong medication
- Stigma due to visual appearance – i.e. Exophthalmos
- Hormone deficiency can manifest as lethargy + malaise - ↓social mobility/interaction, ↑withdrawal
- Burden on family + relationships – others having to know + recognise signs + symptoms of acute complications ->i.e. Addisonian crisis.
- Infertility – impacts relationships
how is renal injury and renal failure prevented?
- TIGHT BP control
- Glycaemic control
- Use of ACEi
- Meds review – avoid nephrotoxins
- Avoid dehydration – drink plenty!
- Monitor – in acutely ill + elderly
what are the resource implications of organ transplantation and blood donation?
•Cost effectiveness – £38,000 with CKD stage 4, £21,000 on dialysis, 76% on HD, 24% on PD
oHaemodialysis ~ £35,000 p.a. FOREVER, Peritoneal ~£17,500 p.a.
oTransplant - £17,000 for procedure, £5, 000 p.a. thereafter, for immunosuppression
oTherefore transplantation ->£25,800 SAVING p.a. every year post-transplant
•In 2009 dialysis of those on waiting list cost £193m – if all had a transplant – SAVE £152m p.a.
what is a market?
network of buyers and sellers exchanging goods and services, regulated by explicit and implicit rules.
describe the altruistic view towards transplant donation?
regard for others as a principle for action. You’d hope for reciprocity if in need yourself
•Altruism + trust may also play a role in exchange/trading, not only monetary payment.
•Altruism is the basis for donor schemes -> efficient?
describe the gifts/commercial principles of transplant donation?
Wouldn’t it be better to use commercial mechanisms to encourage donation, and maintain an adequate supply?
describe the altruistic view for blood donation?
ethical case vs. blood market (Titmuss)
•Represses altruism
•Erodes sense of community
•Sanctions ‘profits’ in healthcare provision
•Increases blood supply from poor or the unemployed ->rich
•May increase infection
describe the blood market view for blood donation
- No different from any other tradable good
- Supply with increase by removing donor obstacles
- Financial rewards/exemption from future payment.
what is the argument for having a market for used body parts?
- Transplantation is most efficient treatment (best use of resources) + better quality of life.
- Dialysis expensive + poor quality of life. 2500 transplants vs dialysis ‘saves’ NHS £50m pa
- Altruistic supply of organs is dwarfed by demand ->clinicians have to ration this resource.
- Rationing = patients dead on the waiting list -> who deserves priority for the transplant?
- In Iran it has been proven to increase supply!
how could donations be improved?
- Continental Europeans assume consent to harvest without relatives.
- Opt out rather than opt in donor system -> evidence unconvincing, still reliant on altruism.
- Use of transplant co-ordinators and clinical leads in hospitals
- Financial incentives – may impinge on quality control?
describe some other global organ donation policies?
- India – mandatory to request donation in brain stem death
- Spain - ↑est donation rate, has opt out policy – ‘soft’ seek relatives views
- Austria – ‘hard’ opt-out system -> don’t seek relatives views
- China – donations come from executed prisoners who have ‘all consented’…
- Iran – allows sale of kidneys for profit - has no waiting list/shortage
describe the human tissue act (2004)?
Consent needed for ‘scheduled purposes’ = storage + use of tissues of living/deceased, including research ‘in connection with disorders or functioning of the human body.
•CONSENT underpins the entire process of organ donation
describe the role of the independent assessor in donation?
•Under the Human Tissue Act (2004) all donors and recipients are required to see an Independent Assessor (IA)
o trained and accredited by the Human Tissue Authority
o Not involved with the healthcare team
•The purpose is to ensure:
o Donors not forced against their will
o No reward has been sought/offered in exchange for donation
o Donor has capacity to make an informed decision
how does transplantation service ration the limited supply?
- Everyone in need of transplant is entered onto national database
- DBD – allocated via national allocation scheme (NHSBT)
- DCD – allocated regionally – one kidney always offered preferentially to the local transplant centre
describe the evidence based computer algorithm used to rank recipients for transplantation?
tier A = 000 mismatched paed patients-highly sensitised or HLA-DR homozygous
tier B = 000 mismatched paediatric patients -others (all except A)
tier C= 000mismatched adult patients-highly sensitised or HLA-DR homozygous
tier D=000 mismatched adult patients-others (except C), favouraby matched paed patients (100, 010,110)
tier E=all other eligible patients
tiers C,D,E prioritised according to points bessed system
what is taken into consideration for the donor point system
- Waiting time – 1 point/day • HLA match + age combined (↑ for ↓age + less mismatches)
- Donor-recipient age difference -↓ for ↑age difference
- Location
- HLA-DR homozygosity
- HLA-B homozygosity
- Blood group match
should age be taken into consideration at a macro level for organ transplant?
YES: Treatment/care of elderly is expensive…BUT…
Burden of cost not related to age per se, more to costs of illness + incapacity in final years.
Even so, isn’t this price worth paying for an equal society? Devalues elderly, fostering a trend of inequality between the old and the young.
YES: Fair innings argument – they’ve had their time and young people haven’t, so they should forgo treatment..BUT…
What is a full life? Have they had quality of life?
Why does length bear impact if outcomes would be better for elderly? Many other factors to account for.
should age be taken into consideration at a micro level for organ transplant?
YES: Older people are less likely to respond to treatment…BUT…
Age alone not a good predictor of responsiveness to treatment or of prognosis
Denying treatment due to age is discrimination (made illegal under The Equality Act, 2010)
o Direct discrimination = one person being treated in a less favourable manner than another in a comparable situation, based on age (or gender, religion, ethnicity, culture, sexuality etc.)
o Indirect discrimination = seemingly neutral provision/measure/practice has harmful repercussions on a person (i.e. universally applied hospital discharge policy may be harmful to elderly who haven’t had necessary time for recovery)
o GMC say you “…must not unfairly discriminate..” blah blah etc.
