Prevention medicine Flashcards
prevention + epidemiology in medicine
1
Q
what is DALY? (name the top causes of DALYs + risk factors contributing to disease)
A
- DALY = disability adjusted life years -> sum of years of life lost due to premature mortality/ disability
- top causes: Ca, CV, mental health, msk, injuries
- top contributing factors to burden of disease = increase BP, smoking tobacco, physical inactivity, excessive alcohol consumption + overweight
2
Q
what are some success stories of prevention?
A
- antismoking campaign
- motor vehicle safety
- communicable disease
- workplace safety
- vaccination
3
Q
what are the approaches to prevention? (which one is the most effective?)
A
high risk (individual strategy) and public health (population strategy) -> public health is more effective
4
Q
what are some advantages of public health vs individual strategies?
A
public health advantages
- behaviourally appropriate as tries to change underlying cause of disease
- small change can make a large impact across a population
individual strategy advantages
- dr + pt motivated to use
- favourable benefit:risk
- cost effective use of resources
- appropriate for individual
5
Q
what are some disadvantages of public health vs individual strategies?
A
public health disadvantages
- lower benefit:risk ratio
- not as motivated to use
- prevention paradox
individual strategy disadvantages + limitations
- behaviourally inappropriate
- temporary effect
- unknown absolute risk
- costs + problems associated with screening
6
Q
what is the prevention paradox?
A
when a preventative measure offers little benefit to each participating individual but provides a large benefit to the population
7
Q
what is public health vs individual strategies?
A
public health
- tries to shift underlying determinants to favourable condition
individual strategies
- high risk individuals located, screened opportunistically
8
Q
what are the prevention levels and what do they consist of
A
primary - prevent disease
secondary - early detection to improve management
tertiary - management to prevent complications
9
Q
what is screening?
A
- screening IS NOT Dx
- series of questions, tests etc. to identify individuals that can be helped rather than harmed by further investigation
10
Q
what are the screening guidelines?
A
1) condition
- must be recognisable (latent and symptomatic stage), NB (i.t.o. significant morbidity/ mortality), natural Hx should be understood
2) test
- safe, simple, valid, reliable, acceptable
- must have cut off numbers
3) treatment
- must be effective treatment available
- must have evidence that early treatment leads to better outcomes
4) outcome
- must have evidence of better outcomes (mortality/ morbidity reduced/ increased QOL) with early detection
- cost of case finding must economically balance cost of potential expenditure
5) consumer
- must be informed of evidence = can make informed decisions
11
Q
what is prevalence?
A
number of people in that point in time with disease
12
Q
what is incidence?
A
gives idea of risk of getting disease
13
Q
what is absolute risk and how do you calculate it?
A
absolute risk = number of events/ total people in group
probability that specified event will occur in specified group
14
Q
what is relative risk and how do you calculate it?
A
RR = ARE/ARC
ratio of risk of disease among exposed WITH disease and exposed WITHOUT disease
- used in LONGITUDINAL/PROSPECTIVE study
15
Q
what is attributable risk and how do you calculate it?
A
AR= ARE-ARC expressed per 100 000
amount of risk that can be attributed to exposure
- used in LONGITUDINAL/PROSPECTIVE study
16
Q
what is odds ratio and how do you calculate it?
A
OR= odds of being exposed WITH disease/ odds of being exposed WITHOUT disease
OR = ad/bc
- ratio of 2 odds to give approximate value of risk of exposure
17
Q
what is validity?
A
ability of test to measure what its intended to measure
18
Q
what is reliability?
A
ability of test to measure what its intended to measure between tests, testers and time
19
Q
what is sensitivity and how do you calculate it?
A
- sensitivity = probability that test is positive in those who truly have the disease
- when sensitive tests are negative they help rule out disease (SnOut)
- Sn= CP/total diseased
20
Q
what is specificity and how do you calculate it?
A
- specificity = probability that test is negative in those who do NOT have the disease
- when specific tests are positive they help rule in disease (SpIn)
- Sp = CN/ total healthy
21
Q
what is positive predictive values and how do you calculate it?
A
- PPV is the probability of a test to have a true positive (probability disease is present given test is positive)
- PPV = CP/ total positive
22
Q
what is negative predictive values and how do you calculate it?
A
- NPV is the probability of a test to have a true negative (probability disease is NOT present given test is negative)
- PPV = CN/ total negative
23
Q
what is numbers needed to treat and how do you calculate it?
A
- NNT = amount of people who would have to be treated in order for 1 person to benefit from treatment
- NNT= 1 / ARR reduction
note ARR reduction = ARR higher %- ARR lower %
24
Q
what is numbers needed to harm and how do you calculate it?
A
- NNH = amount of people who need to be exposed to risk factor to cause harm in 1 pt (that would otherwise not be harmed)
- NNH =1/AR
25
what are the 5As
1. ask
2. assess
3. advise
4. assist
5. arrange
26
which of the 5As are used in the stages of the transtheoretical model?
1. precontemplation = ask, assess, advise
2. contemplation = ask, assess, advise, assist
3. preparation = ask, assess, advise, assist, arrange
4. action = ask, assist, arrange
5. maintenance = ask, arrange
27
what is the GRACE model?
```
USED IN MOTIVATIONAL INTERVIEWING
G - generate gap
R- roll with resistance
A- avoid arguments
C- can do attitude
E- express empathy
```
28
what nutritional modifications would you make for a vegetarian?
- firstly ask "what does that mean to you"
- protein requirement stays the same but protein source changes (legumes, eggs)
- some challenging micronutrients
29
what nutritional modifications would you make for someone who has food allergies/ intolerances?
- require alternative source/ supplements
| - too many = refer to dietician
30
what nutritional modifications would you make for someone who has a chronic disease?
1) CKD
- less Na
- smaller portion of proteins
- heart healthy food (less oil and fat, grill, boil and bake)
- progresses = less phosphorous
- manage appropriate K+ levels as K+ build up leads to CV problems
2) coeliac - NO GLUTEN modify cereal
3. T2DM - low fat, low GI, reduce simple sugars
4. T1DM - diet is less NB (low GI preferred)
31
in assessing nutrition what are the 2 basic issues
1. assessing the nutritional state
| 2. reason behind the nutritional state
32
how do we test for nutritional state?
1. blood tests
- ALBUMIN + PREALBUMIN (both low in malnutrition) as inflammation is a risk factor for malnutrition -> need to assess proteins + CRP to see if previously mentioned is due to inflammation/ malnutrition
- UREA
- VITAMINS
2. NFPE (nutrition focussed clinical exam)
- check for:
* oedema,
* muscle wasting and
* subcutaneous fat loss
33
list the BMI values + their associated nutritional categories
- <25 = NORMAL
- 25-30 = OVERWEIGHT
- 30-35 = GRADE 1 OBESITY
- 35-40 = GRADE 2 OBESITY
- >40 = GRADE 3 OBESITY
34
outline some facts around obesity and their implications
1) moderate environmental changes can aid in weight loss (even in genetically susceptible people)
2) diets are good for short term use, ultimately you need overall reduction in energy intake
3) regardless of weight, increased exercise will increase health
4) sufficient physical activity will aid long term weight maintenance
5) need to continue with weight loss management as obesity is CHRONIC condition
6) for overweight children programs at home + parents promotes greater weight loss
7) meal structure promotes weight loss
8) pharmaceutical agents can aid in weight loss
9) in appropriate pt bariatric surgery reduces incidence of diabetes and mortality
35
what are some conditions associated with obesity?
1) associated with metabolic weight
- greatly increased risk of: T2DM, HTN, insulin resistance, dyslipidaemia, non alcoholic fatty liver syndrome, gall bladder disease
- moderately increased risk of: CHD, stroke, gout
- slightly increased risk of: cancer, reproductive abnormalities, polycystic ovaries, skin complications and cataracts
2) associated with excess weight
- greatly increased risk of: sleep apnoea, breathlessness, asthma, social isolation/ depression, fatigue/ lethargy
- moderately increased risk of:
hernia, OA, respiratory disease + psychological problems
- slightly increased risk of:
varicose veins, msk problems, back problems, stress incontinence, oedema, cellulitis
36
what are some treatment strategies for obesity?
1) good evidence for:
- fitness programme
- counselling
- meds
- prep meals
- meal replacement
- surgery
- lifestyle change
2) limited evidence for:
- alternative treatments
- diet programmes
- self directed diets (Atkins)
3) NO EVIDENCE FOR
- OTC products, herbs + other supplements
37
what are the indications for bariatric surgery?
1) BMI >40 OR BMI 35-39.9 + life threatening cardiopulmonary disease, severe diabetes or lifestyle impairment
2) failure to achieve adequate weight loss with nonsurgical interventions
38
what are the CONTRAINDICATIONS for bariatric surgery?
1) Hx of noncompliance
2) psychiatric illnesses (PD, uncontrolled depression, suicidal ideation + substance abuse)
3) unlikely to survive surgery
39
what are the effects of exercise on the body?
- Increased lean body mass & decreased fat mass
- Increased bone mineral density
- Increased cardiac output
- Increased oxygen carrying capacity & exchange
- Increased metabolic rate
- Improved neurotransmitter regulation, mood, self-efficacy
- increases strength + endurance, improves balance and coordination, become fitter and lose weight
40
what is the difference between exercise and physical activity?
- PA= athletic, recreational/ occupational activities that require physical skills and utilise strength, power, endurance, speed, flexibility, range of motion/ agility
- exercise = PA that is planned, structured + repetitive for conditioning any part of the body (improves health, maintains fitness and is NB for rehab)
41
what is incidental activity?
any activity built up in small amounts over the day.
| EG walking up the stairs
42
```
what is:
- sedentary
- light intensity
- moderate intensity
- vigorous intensity
AND high intensity activity?
```
- sedentary -> mostly sitting activities + associated with health risks
- light intensity -> aerobic activity that doesn't noticeably change breathing rate EG. domestic/ occupational tasks (no proven benefit)
- moderate ->aerobic activity that can be maintained whilst talking EG walking, golf etc (30min per day is beneficial)
- vigorous -> aerobic activity that makes you breathe harder + conversation can not be maintained uninterrupted EG. jogging, aerobics
(most health benefits)
- high -> rate of energy expenditure, cannot be sustained for longer than 10min generally eg. elite athletes
43
what is the recommended guideline for exercise in an adult?
```
5x 30min/ week moderate intensity
OR 3 x 20min vigorous activity
PLUS 2-3x week resistance
each session lasting at least 10min
(150min to maintain weight and 250 min to lose weight)
```
44
what are the benefits of PA on CV disease management?
- in clinically stable people:
anti-atheroscletrotic, antithrombotic, anti-ischaemic and anti-arrhythmic
- reduces load on heart which relieves some symptoms
- improved physical function + psychological wellbeing + favourable changes in body weight
- precautions: absolute and relative AND medication effects
45
what are some of the psychosocial barriers to exercise in cardiac rehab + what are some strategies to overcome these?
- non participation = lack of referral, associated illness, self efficacy, perceived benefits, self motivation, support + occupation
- non adherence = old age, female, angina, fewer years of formal education
STRATEGIES TO OVERCOME
- educate + reassure
- enhance referral pathways + avoid bias when referring
- emphasise multiple risk reduction programs
- target women + elder early postMI
- enter rehab no more than 3 weeks after event
46
what is the difference between an exercise scientist and accredited exercise physiologist?
1) exercise scientist
- work with the apparently healthy (children -> after school programs, adults -> community projects, elderly -> group exercise)
2) accredited exercise physiologist
- prevention, management and rehab
- work with people who have multiple pathologies
- provide exercise prescription + lifestyle support for chronic disease
- lifestyle counselling + behavioural coaching.
- Health education.
- Self management support.
- Exercise support and monitoring of behaviour changes.
- exercise counselling, prescription and physical rehabilitation.
47
explain the GP-AEP partnership
- AEPs have medicare provider numbers (can refer as part of your care plan)
- private health insurance recognises AEPs as allied health
- WRITE REFERRAL LETTER + CHAT TO AEP
48
what are the 5 strategies of the Ottawa Charter for Health Promotion?
1) build healthy public policy (smoking bans, plain packaging)
2) create supportive environments (smoke free venues)
3) strengthen community action (right to object workplace smoking)
4) reorient health services (NRT, counselling etc)
5) develop personal skills (learn giving up strategies)
49
outline the childhood vaccine schedule
birth
- Hep B (IM, 24hrs - 7 days after)
- TB (A&TSI intra dermal)
2 months AND 4 months
- DTPa-hepB-IPV-Hib
- pneumococcal
- rotavirus (oral admin: 1st dose <15 weeks and 2nd dose <25 weeks)
6months
- DTPa-hepB-IPV-Hib
- pneumococcal (A&TSI), children with risk factors/ premature infants born <28weeks)
6 months to <5years
- influenza (two doses required with min 1 month in between doses)
12months
- MMR
- Meningococcal ACWY
- pneumococcal
- hep a (A&TSI)
- hep b (prem baby <32 weeks gestation OR <2000g birthweight)
18months
- MMR- varicella
- haemophilius influenzae type b
- DTPa
- hep A (A&TSI)
4 years
- DTPa-IPV
- pneumococcal (children with risk factors)
50
what are the different types of vaccines?
```
1) live vax
= attenuated
= similar non disease causing organism
- robust immune response
- potential to cause disease/ can't be used in immunocompromised pt/ pregnant women
- potential for adverse/ side effects
- lifetime immunity with 1/2 doses
```
```
2) killed/ inactivated vax
= heat, formalin, radiation
- less robust immune response
- no ability to cause disease
- fewer adverse side effects
- requires multiple doses + may require a booster
- waning immunity
```
3) acellular vax
= capsule, flagella, part of protein cell wall, subunit vaccines
4) toxoid vax
= toxin treated with aluminium, absorbed into aluminium salts
5) adjuvants and conjugates
= agents incl other vaccines that increase the immune response
review of acellular, toxoid/ subunit
- less robust immune response
- may require adjuvants/ conjugates
- requires multiple doses + may require booster
- waning immunity
51
outline the transmission, incubation and period of communicability of measles
- family: paramyxoviridae
- genus: morivillivirus
- occurence: prior to immunisation 100 million cases and 6 million deaths -> 99% drop in cases
- transmission: airborne droplet spread
- incubation: 10 days to onset of fever and 14 days to onset of rash
- period of communicability: from prodrome to 4 days after onset of rash
- susceptibility:
* universal w/o vax
* illness- lifetime immunity
* after 1st vax 95% immune and after 2nd vax 99% immune
* maternal Ab protect for 6-9months
52
what is the case definition for measles?
- prodrome = fever + malaise
- cough, coryza, conjunctivitis, maculopapular rash starting on face and spreading to rest of body + koplik spots
- note: exposure risk
- note: vax Hx
53
what are complications arising from measles?
- Otitis media – 9%
- Pneumonia – 6%
- Diarrhoea – 8%
- Acute encephalitis – 1/1000 (0.1%) mortality 10-15% + up to 40% of survivors with permanent neurologic sequelae
- SSPE – rare 1/100,000 -> 7 years post infection -> Universally fatal
54
outline the measles vaccine: type, contraindications and interactions
type: live (either MMR/MMRV)
contraindications: pregnancy, immunosuppression
interactions: interferes with other live vaccines (EG. BCG)
note: dosing interval is 4 weeks (1st dose 12 months and 2nd dose is 18 months)
55
outline the transmission, incubation and period of communicability of rubella
- family: togavirus
- genus: rubivirus
- occurence: prior to immunisation epidemic every 5-9years; post vax almost eliminated
- transmission = airborne droplet spread, contact with mucous membranes (infants with CRS shed virus in pharyngeal secretions and urine)
- incubation= 14-21 days
- period of communicability -> 1 week before and 4 days after appearance of rash; infants with CRS may shed virus for MONTHS after birth
- susceptibility: universal w/o vax/ prior infection (after single dose 95-100% immunity - lifetime immunity)
MATERNAL Ab PROTECT INFANT FOR 6-9MONTHS
56
what is the case definition for rubella?
- 50% kids asymptomatic
- Generally mild, self limiting
- Low grade fever
- Headache
- Malaise
- Coryza, conjunctivitis
- Lymphadenopathy
- Arthralgia
- Rash
57
what are rubella complications?
1) post viral encephalitis
2) congenital rubella syndrome
- maternal infection with rubella during 1st trimester
- 90% infants affected
- multiple defects common (deafness + neurological)
IF PREGNANT WOMEN GET RUBELLA NEED OT GIVE IMMUNOGLOBULIN TO PROTECT BABY
58
outline the rubella vaccine: type, contraindications and interactions
type: live, attenuated
(MMR/MMRV/ monovalent rubella vax)
contraindications: PREGNANCY
interaction: interferes with other live vaccines
- give 1st dose -> 12 months; give 2nd dose-> 18 months
- give to all seronegative women of childbearing age
59
outline the transmission, incubation and period of communicability of pertussis
- whooping cough: bordetalla pertussis
- occurence: epidemics every 3-4 years; outbreaks large in unvaccinated pop
- transmission: airborne droplet spread, HIGHLY INFECTIOUS
- incubation: 7-20 days
- period of communicability: 21days after onset of cough
- susceptibility: infants who haven't received 2 doses of vax, adults/adolescents with waning immunity
NOTE: maternal Ab does not provide reliable protection
60
what is the case definition for pertussis?
1) acute cough (≥14 days) with at least one posttussive vomiting, apnoea/ whoop
2) cough of any duration in person epidemiologically linked to lab confirmed case
3) lab evidence of bordatella pertussis (culture/ PCR)
61
what are pertussis complications?
- morbidity/ mortality
- > 7% of cough illness per year in adults
- > if cough persists for up to 3 months -> sleep disturbance/ rib fracture
- > Case fatality rate in infants <6 months is 0.8% (in Australia, higher in low resource settings)
- > Causes: pneumonia, seizures and hypoxic encephalopathy
62
outline the pertussis vaccine: type, schedule and interval restrictions
type: acellular
(various combos -> DTPa/ dTpa)
schedule: 2,4,6 months (booster at 4 years = DTPa + 12-17 years = dTpa)
NO interval restrictions
63
what are general contraindications to vaccines?
1) absolute (anaphylactic response to vax/ component)
2) relative (immunocompromised - live vaccines; pregnant/ may be pregnant - live vaccines; fever >38.5ºC; recent live vax <4weeks; recent <7 months blood/ blood products EG immune globulin; GBS (influenza)
CAN STILL VACCINATE IF:
- surgery, underweight, mild illness, fam Hx of adverse of effects, history of seizure, current antibiotic therapy, neurologic conditions, prematurity, pt's mother is pregnant
64
what are the 5 vaccine related adverse effect categories?
1) vaccine prod related reaction
2) vaccine quality related reaction
3) immunisation error related reaction
4) immunisation anxiety related reaction
5) coincidental event
65
which additional vaccines are given to high risk children and A&TSI pop?
Aboriginal + Torres Strait
1) Hep A
- first dose 12-24 months old
- may be admin with hep B
- A&TSI children in high risk areas (esp QLD)
2) Pneumococcal
3) influenza
4) Japanese encephalitis (outer islands of Torres strait)
High risk (COPD, neuro shunts, splenectomy)
- influenza
- pneumococcal
66
in which diseases can vaccination prevent outbreaks?
- some vaccines can be used to prevent secondary cases in an outbreak situation
- Depends on the onset to protection and the incubation period
- usually NARROW TIME FRAME
• MMR
• Diptheria (can also use antibiotic prophylaxis)
• In some cases meningococcal (usually use antibiotics in this case)
67
what are some occupational vaccines
- not necessarily gov funded, sometimes employer/ self funded
- some occupations have higher risk that alters cost effectiveness and risk:benefit of getting vaccinated
EG.
1) healthcare -> influenza, Heo B, MMRV, DTPa, +- Hep A, +-BCG
2) abattoir workers, farmers: Q fever
3) vets: influenza, Q fever, rabies
68
explain what happens in Bat Lyssavirus exposure
- bat lyssavirus closely related to rabies
- found in some bats
- people handling bats should be vaccinated against rabies
- exposure need PROMPT post exposure prophylaxis (vaccine +- IgG)
= unvaccinated -> human rabies immunoglobulin INTO wound + vaccinate IM at the same time (day 0) at distant site + repeat vaccine at 3,7 and 14 days
= vaccinated: 2 boosters -> day 0 and 3
69
why is influenza vax NB?
- sporadic cases, epidemics, pandemics (Spanish flu, Asian flu, Hong Kong flu, swine flu)
SPANISH flu
- infected 20-40% world pop
- killed around 50 million people
- unusual mortality (worse in 20-40yo)
INFLUENZA
- highly infectious
- antigenic drift from year to year
- in Aus causes 3,500 deaths, about 18,000 hospitalisations and 300,000 GP consultations each year.
- 10% of annual work absences
- Death rate 40x higher with chronic disease
- Only 50% of healthcare workers get vaccinated!
70
use polio as an example of risk: benefit balances when deciding whether vaccines are appropriate
polio = almost universal, spread is person to person/ faecal oral so VERY difficult to stop with so many asymptomatic people
- 2 vaccines developed OPV/ IPV
- OPV = live, attenuated + more effective BUT has risk of causing disease in immunosuppressed + at-risk people (still preferred in countries at risk of polio)
- IPV less effective but safer
ALL INTERVENTIONS are balance of risk:benefit (NB to report adverse events)
71
what are some current/ recent vax changes?
ZOSTER VAX (70+)
- Boost immunity to varicella to prevent shingles
- NOT the same as varicella vaccine (monovalent or MMRV)
- LIVE vaccine and MUST NOT be given to immunocompromised individuals
MENINGOCOCCAL QUADRIVALENT
- ACWY
- Changing pattern of meningococcal disease
- Currently a one-off adolescent program, being added to
childhood schedule
- Changed Rotavirus vaccine type and schedule
- Changed HPV vaccine type and schedule
72
what is an injury?
```
EXCHANGE OF ENERGY
• acute physical damage to the body + much more:
- Physical (car crash / fall)
- Chemical (poisoning / burn)
- Heat (burn / scold)
- Noise (hearing loss)
- Vibration (white hand)
- Long term (RSI)
- Motion (back strain)
- Psychological (suicide)
```
73
what is the cost of injury in Aus?
185 000 DALYs
7% of total morbidity and mortality burden
$13.3 billion
74
what is injury prevention?
* prevention of incident which would have resulted in injury
* reduction of exchange of energy (reduce severity)
* minimisation of damage caused
* Early response + rehab
75
which gender is more likely to injure themselves and why?
- males
* peer pressure/ masculinity
* risk taking
* alcohol consumption
* mental health
76
what are the levels of the injury iceberg?
1) intrapersonal (behaviour, bio and psychological)
2) interpersonal (home, family, peers)
3) organisational (work, health org, clubs + associations, school)
4) community (utilities + roads, public facilities, social capital, social class, ethnicity)
5) society (infrastructure, health facilities, economics, education, gov policy, national psyche)
77
what are some data sources for injury surveillance + what are their strengths and limitations?
1) coroner
S: pop base, careful investigation, good details about circumstance
L: legal agenda, legal standard of proof + missing data
2) ABS
S: pop based, comparable
L: limited detail
3) hospital separations
S: pop based, admission, comparable
L: limited detail, retrospective, part of larger system
4) trauma registry
S: good case definition, comparable outcome
L: retrospective, case ascertainment, event descriptor poor
5) ED
S: immediate, large number of cases, ability to capture case info
L: capture of detail, minor injury
78
describe the pre-event, event and post-event for injury in the Haddon Matrix
1) pre-event
- prevent existence of the agent, prevent release of the agent, seperate the agent from the host, provide protection for the host
2) event
- minimise amount of agent present, control pattern of release of the agent to minimise damage, control the interaction btw the agent and host to minimise damage, increase resilience of host
3) post-event
- provide rapid treatment response for host, provide treatment + rehab for the host
79
what are the Es of injury prevention?
1) environment
- change to make safer
2) enforcement
- enforce to ensure compliance
3) education
- make people aware of the issue
4) evaluation
- ensure the intervention works
5) engagement
- bring all parties to the table
6) epidemiology
- study of the factors
7) economic impact
- understanding of the costs
8) empowerment
- local action
80
what is the communication paradox?
- big numbers, less impact (seems like problem is too big to handle)
- personal story is more powerful (emotion, connection and transference)
81
what are the 5 steps of project planning?
1) DEFINE PROBLEM
- assess needs + identify key issues
- set priorities
- define target group
- establish rationale
- reality check (does it really matter?)
- how would you define success/ measure it
2) ANALYSE PROBLEM
- brainstorm the problem
- identify the key sub-components of the problem
- flip to objectives
- reality check
- how would you define success/ measure it
3) ASCERTAIN KEY DETERMINANTS
- brainstorm determinants of each sub problems
- try to take comprehensive view (ID behavioural, environmental + social determinants)
- review your "conceptual map" of the chain causation (how do the sub problems cause main problems? how do various determinants cause sub problems? where are the best opportunities to interrupt this sequence of events?)
- design strategies to address the determinants
- reality check (can you implement strategies? are they worth the effort)
4) IMPLEMENT THE PROGRAM
- review each strategy in turn & answer the following 5 questions:
- WHAT? WHO? WHERE? HOW? WHEN?
- what: needs to be done/ barriers to success
- who: is going to take responsibility, needs to be involved, do you need to help?
- where: are the people you need to help/ resources you need to succeed/ barriers to success
- how: are you going to get the resources you need, going to overcome any barriers to success etc
- when: does it need to be done by?
5) EVALUATION
- does it work?
- SMART
S - SPECIFIC
M- MEASURABLE
A- ACHIEVABLE
R- RELEVANT
T- TIMELY
- outcome evaluation (did you achieve your goals)/ impact evaluation (did you achieve your objectives)/ process evaluation (did your strategies work)
82
what do you need to include in a referral?
1) background -> enough about the pt to get them started + avoid unnecessary repetition (diagnoses, test results, meds etc.)
2) goal of the referral -> what you want them to do (one off opinion, ongoing assistance, take over main management, perform operation)
3) urgency/ time-frame
4) who else is involved
5) ensure contact details are ok, ensure pt knows procedure for getting appointment, follow up arranged + what to do if things get worse while waiting
83
what are some pitfalls to avoid in chronic disease management?
1) diagnosis
- screening ≠ diagnosis
- need to explain properly (common problems are under/ over selling)
2) how we give advice
- language (do not use scientific)
- always start where the pt is
3) know what you know + what you don't
- everyone is different
- pt knows their own disease + body better than you do!
4) measuring isn't managing
- if you do nothing with the measurement you're wasting the pt time + money
- management comes after measurement
5) blaming the pt
- never ever ever ever helpful
6) LABELS
- seems subtle but eats away at your attitude (avoid bad, good, compliant/ non compliant)
7) PCC
- don't reduce people to a number, label or disease
8) under management (puts all onus on pt to do better w/o managing anything/ telling pt how they can do better)
9) over management (disempowers pt, find solutions WITH pt)
10) expecting perfection
- NOBODY IS PERFECT -> be kind to humans
84
what are primary prevention strategies for chronic disease?
- diet
| - physical activity
85
what are secondary prevention strategies for chronic disease?
- early detection
| SCREENING RULES
86
what are tertiary prevention strategies for chronic disease?
- all about preventing deterioration, recurrence/ complications of disease
- good chronic disease Mx all about tertiary prevention
87
what do we need to know when managing CV disease?
- age + sex
- smoking status
- serum lipids
- bp
- waist circumference + BMI
- nutrition
- physical activity level
- alcohol intake
- fam Hx of prom CV disease
- indigenous stat
- social Hx
- diabetes
- urine (micro albumin and protein)
- familial hypercholesterolaemia
- evidence of existing cardiac issues
88
how do you calculate CV risk and how do you reduce it?
CV RISK
- Absolute risk
- A&TSI >35years
- adults with diabetes 45-60yo
- adults overweight/ obese = usefulness not determined
- in adults with AF = risk high, undetermined use
MODIFIABLE FACTORS
- to reduce CV risk, need to address modifiable risks
- lifestyle factors (weight, physical activity and smoking stat)/ can be reducing BP/ lipids
89
What are the PBS guidelines for people with diabetes?
- treat any level of hyperlipidaemia if indigenous, over 60/ microalbuminuria
- others -> treat if total cholesterol >5.5 mmol/L
- NATIONAL HEART FOUNDATION TARGETS:
total cholesterol <4.0 mmol/L
triglycerides <1.5mmol/L
HDL-C >1.0 mmol/L
LDL-C <2.5 mmol/L
90
what are some primary prevention techniques for diabetes?
- currently little for T1DM
- T2DM PREVENTION:
* TARGET GROUP
- pre diabetes (impaired glucose, tolerance, impaired fasting glycaemia, gestational diabetes)
- + those with elevated AUSDRISK score/
- with other specific risk factors with negative screening test
* INTERVENTION
- > increase physical activity
- > give advice on healthy low fat diet (low fat, high fibre, low GI with cereals, legumes, veggies and fruits), weight loss + increased physical activity
- refer pt to a dietician and physical activity program
- provide pre-conception advice to women with hx of gestational diabetes
91
what are some secondary prevention techniques for diabetes?
- AUSDRISK
- early detection
- good initial management
- lifestyle intervention can potentially reverse Dx/ prevent progression/ complications
92
when do we screen for diabetes?
- every 3 years from 40yo using AUSDRISK
- A&TSI should be screened from 18yo (every 3 years)
- those with risk of 12+ should be tested by fasting plasma glucose
93
who is at high/ increased risk for T2DM?
increased risk
- age >40yo
- A&TSI peoples
```
high risk
- any of the following:
º AUSDRISK 12+ score
º Hx of CV event
º women with Hx of gestational diabetes
º women with PCOS
º pt on antipsychotic drugs
º those with impaired glucose tolerance test/ impaired fasting glucose (need to test every 12months)
```
94
what are the tests to detect diabetes?
1) fasting blood sugar
- measure glucose on fasting plasma from VENOUS blood:
<5.5 mmol/L diabetes unlikely
5.5-6.9 mmol/L may need to perform oral glucose tolerance test
7.0 mmol/L (or >11.1 non-fasting) -> diabetes likely, repeat fasting glucose to confirm on a seperate day
2) oral glucose tolerance test
- before and 2 hours after 75g oral glucose load is taken orally plasma glucose is measured
- if >11.1 mmol/L diabetes likely
- if btw 7.8-11.0 mmol/L impaired glucose tolerance
- <7.8 mmol/L diabetes unlikely
3) diabetes risk (AUSDRISK)
- score related to risk of developing diabetes over a 5year period
4) glycated haemoglobin (HbA1c)
- dx test
- 6.5% diagnostic test cut off
