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Finals > Public health > Flashcards

Public health Flashcards

1
Q

what are the types of harms with primary medicine of abuse (the main ingredient)

A
  • addiction: benzo, opiates
  • follow-on abuse: alcohol, illicit drugs
  • electrolyte imbalance: laxatives
  • withdrawal syndrome: SSRIs
  • convulsions/acidosis: chlorphenamine, antihistamine
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2
Q

what are the types of harm in the additional ingredient?

A
  • GI (indigestion bleed, death): ibuprofen
  • Hypokalaemia + acidosis: ibuprofen
  • Hepatotoxicity, death: paracetamol
  • rebound headache: paracetamol
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3
Q

why is there a problem for both OTC and prescription drugs?

A
  • definitional + diagnostic issues
  • range of treatments + strategies used
  • those affected do not want to be identified or have addictions recorded
  • harms + behaviours may not be as pronounced as some other addictions
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4
Q

what are the range of treatments and strategies used?

A
  • formal addiction services
  • self-help
  • involvement of GP
  • online support
  • Narcotics Anonymous
  • private clinics
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5
Q

Name some prescription medicines associated with abuse + dependency

A
  • opioids
  • benzodiazepines
  • Z-drugs (zopiclone, zolpidem)
  • SSRI antidepressants (fluoxetine
  • GABAergics (gabapentin, pregabalin
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6
Q

Name some OTC medicines associated with abuse and dependecy

A
  • analgesic codeine w/ paracetamol
  • opiate cough medicines (codeine linctus)
  • sedative antihistamines (sleep)
  • laxatives
  • nicotine replacement therapy
  • decongestant stimulants
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7
Q

Risk factors for addiction on OTC medication

A
  • genetic
  • personal psychosocial profile
  • personal or FH of addiction
  • psychiatric disorders
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8
Q

what is the addict identity

A
  • drug seeking behaviour
  • withdrawal
  • loss of control
  • use for different effect
  • few treatment options
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9
Q

what is the perceived stereotypical addict identity?

A
  • chaotic
  • illicit substance
  • alcohol misuse
  • treatment options
  • appearance
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10
Q

what is the professional identity?

A
  • intelligent
  • knowledgeable
  • respectable appearance
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11
Q

what attempts have been done to manage/reduce OTC abuse?

A
  • pharmacy- based (hide products, refuse sales, record sales)
  • harm reduction intervention pilot (GP referral)
  • proposed contract/reduction scheme in pharmacies
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12
Q

what is the revised advice on OTC codeine sales

A
  • 100 packs of co-codamol sold as prescription only medicines
  • indications only for pain (not cold, flu)
  • pack warning ‘can cause addiction for 3d use only)
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13
Q

what did the All party parliamentary group (APPDMG) recommend for OTC addiction?

A

Increased:

  • training for Drs, nurses, AHPs
  • awareness of problem
  • recognition/support for online help
  • info to patients about risks
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14
Q

Name a prescription abuse and addiction strategy

A

Royal College of GP created 4 factsheets

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15
Q

what did the Royal College of GPs focus on their 4 factsheets

A
  • prevention (awareness of at risk patients, good prescribing + monitoring
  • substitute opiate trx eg buprenorphine
  • tapering of benzos
  • shared care encouraged with GP and the stigma of addiciton services
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16
Q

name other approaches for prescriptions and OTC problems

A
  • internet support groups; FRANK, mumsnet, overcount

- social media

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17
Q

NHS imporvement strategy

A

maximises the things that go right and minimise what goes wrong

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18
Q

What is the systems approach

A

errors are consequences rather than causes .

Swiss cheese model; successive layers of defence have holes in it due to active failures or latent conditons. Window of opportunity if all holes align to cause an adverse event.

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19
Q

eg of a system failure

A

Wayne Jowett died at 18 after cytotoxic drug, vincristine, intended for IV was instead injected into his spine

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20
Q

strategies to minimise risk

A
  • system design
  • patient safety alerts
  • simplification + standardisation of clinical processes
  • checklists + aide memoires
  • information technology
  • tools to improve uptake of evidence based trx
  • supporting better team working
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21
Q

name 2 System designs

A

hard defences: engineered safety defences

soft defences: people + systems

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22
Q

name an example of a hard defence

A

ATM machine redesigned so users don’t forget their card in the machine

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23
Q

What was the result of the Wayne Jowett case?

A

Patient safety alert: spinal and LP connectors cannot connect with IV connectors or spikes

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24
Q

example of simplification and standardisation of clinical processes

A
  • checking drugs and identity prior to administration of medication
  • marking a surgical site before an operation
  • SBAR (situation, background, assessment, recommendation)
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25
Q

example of standardised observation

A

national early warning score

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26
Q

examples of checklists and protocols

A
  • surgical safety checklist

- emergency department patient safety checklist

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27
Q

what do you need to balance with a checklist

A

requirement to take action vs requirement to use cognition.

Little time to think and use the checklist allows immediate structured action

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28
Q

emergency department patient safety checklist

A

outlines the clinical tasks needed to complete in the first few hours in their admittance to ED

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29
Q

examples of information technology

A
  • electronic prescribing
  • computerised alerts
  • electronic risk assessment for VTE
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30
Q

name some disadvantages to information technology

A

if not fully integrated and implemented well and doesn’t create whole picture of the patient’s medication needs

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31
Q

identify tools to imporve uptake of evidence based trx

A

Care bundles: contains 3-5 evidence-informed practices which need to be delivered colletively and consistently

e.g. urinary catheter care bundle, clostridium difficile care bundle, peripheral IV cannula care bundle

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32
Q

what is the AMBER care bundle

A

a communication and planning tool which supports a systemic approach to improve the quality of care for pts whose recovery is uncertain and who may be approaching the end of their lives despite trx

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33
Q

approaches to supporting better team working

A
  • team training: simulation

- safety huddle

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34
Q

what makes a successful safety huddle?

A

agreed actions

informed feedback of data

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35
Q

personal strategies for mental preparedness

A
  1. foresight

2. 3 bucket model

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36
Q

what is foresight

A

the ability to identify, respond to and recover from the initial indications that a patient safety incident could take place

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37
Q

what is the 3 bucket model

A

it assesses risky situations

  1. self: lack of knowledge, fatigue
  2. context: distractions, lack of time, poor equipment
  3. task: complex?

the fuller your buckets, the more likely something will go wrong, but your buckets are never empty

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38
Q

define an older person

A

aged 60 and older

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39
Q

name nutritional concerns of older adults

A
  • change in body composition
  • decreased energy requirements
  • sarcopenia/obesity
  • bone loss
  • chronic disease
  • monotonous diet
  • protein
  • B12, B6
  • Folic acid
  • Vit D
  • Calcium
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40
Q

why is energy per kg of body weight reduced with age?

A

lean body mass and basal metabolic rate decreases with age

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41
Q

what are the main uses of energy?

A

BMR, physical activity and thermogenesis

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42
Q

what is BMR determined by?

A

body composition of fat

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43
Q

why do energy requirements decline with age?

A

lower physical activity and lower BMR

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44
Q

what is the requirement of protein for older adults

A
  • yet to be identified so set to be the same as for younger people (0.5g/kg)
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45
Q

what are the vitamin requirements for older adults?

A
  • vit D at 10ug (400IU)
  • older women need more iron
  • everything else are practically identical
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46
Q

common causes of iron deficiency anaemia in an older adult

A
  • less iron intake

- GI bleed

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47
Q

define malnutrition

A

a state of nutrition in which deficiency or excess of energy, protein and other nutrients cause measurable adverse effects on tissue/body function and clinical outcome

both under and over nutrition

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48
Q

causes of malnutrition

A
  • cannot afford food
  • cannot prepare food because of physical disability
  • loss of appetite
  • reduced food intake
  • loss of cognition and vision
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49
Q

intervention for malnutrition

A
  • dietary change
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50
Q

consequences of malnutrition

A
  • loss of uscle tissue and strength: resp muscles and cardiac function
  • mobility
  • reduced immune response
  • poor wound healing
  • loss of mucosal integrity(malabsorption/bacterial translocation)
  • phsychological decline - depression, apathy
  • poor prognosis + increased mortality + morbidity
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51
Q

what is sarcopenia

A
  • a decrease in lean body mass associated with ageing

- may co-exist with obesity: sarcopenic obesity

52
Q

what are the causes of sarcopenia

A
  • reduced physical activity
  • change in body composition
  • malnutrition
  • increased cytokine production
  • reduced sex hormones
  • chronic disease
53
Q

name some psychological and social factors affecting nutritional intake

A
  • isolation
  • neglect
  • psychological (bereavement, depression, dementia)
  • economic
  • social support (meals on wheels)
54
Q

name some phsiological factos affecting nutritional intake

A
  • visual impairment
  • mobility
  • dexterity - arthritis
  • dental health
  • illness/polypharmacy
  • GI changes (taste, hormonal, CCK< gut motility, atrophic gastritis
55
Q

assessment of nutritional status in the older adult

A
  • BMI (18.5-25)
  • demispan
  • height
  • waist circumference
  • skinfold thickness
56
Q

why is BMI not accurate

A
  • oedema

- muscle

57
Q

what is demispan

A

distance from sternal notch to tip of middle finger in coronal plane

58
Q

what is a another way to measure body fat

A

bioelectrical impedance analysis (BIA): lean tissue is a better conductor of electricity

59
Q

how do you assess physiological function

A
  • hand grip strength
  • timed ‘up and go’
  • 30 sec chair stand test
60
Q

what nutritional screening tools are used?

A
  • MUST (Malnutrition Universal Screening Tool)

- MNA (Mini Nutritional Assessment)

61
Q

What is MUST?

A

Malnutrition Universal Screening Tool

help detect individuals at risk of malnutrition

0 - no risk
1 - medium risk
2+ - high risk

62
Q

what is MNA

A

mini nutritional assessment for for aged 65+

18 Qs scored to determine if at risk of malnutrition

63
Q

what is economic evaluation?

A

evaluation of the costs and benefits of 2 or more alternative trxs
so a look at the current trx in terms of costs and patient benefits compared to another new therapy

64
Q

What is QALY?

A

Quality adjusted life year
takes into account quality of life and length of life

for different stages thoughout a patient’s life, they will be assigned a different utility score

utility score x time spent in that health state = total QALY associated with the trx

65
Q

what is ICER

A

incremental cost-effectiveness ratio

the incremental costs of one trx over another, divided by the incremental effects

66
Q

what are the two key features of economic evaluation

A

1) measures cost and outcomes

2) assesses these costs and outcomes for at least two or more trxs

67
Q

cost-effectiveness analysis

A

outcomes are measured in natural units (e.g. incremental cost per life year gained)

68
Q

cost-utility analysis

A

outcomes are measured in quality adjusted life years (e.g. incremental cost per QULY gained)

69
Q

cost-benefit analysis

A

outcomes are measured in monetary units (e.g. net monetary benefit)

70
Q

cost-minimisation analysis

A

outcomes (measured in any units) are the same in both trxs.

This is used when the aim is only to minimise costs

71
Q

what is the ICER if a new trx produces 10 additional years of life more than current trxs and costs £10,000 more than current trxs

A

10,000/10

= £1000 per life year gained

72
Q

What is PROMs

A

Patient Reported Outcome Measures are designed to assess patient health

made up of statements or Q’s which are used to find out specific pieces of info about a pt’s health

these items are scaled or scored to give you a measurement

73
Q

how would you measure benefits of a trx?

A
  • PROMs

- QALY

74
Q

How to calculate QALY

A

length of life expected to be gained by the new trx x QoL a patience can expect to have

75
Q

single QALY

A

= one year in perfect health

76
Q

what are the elements required to find the Q in QALY

A
  1. describe the health state that is going to be valued
  2. value the health state described
  3. need a group of ppl to provide the values
77
Q

what is the health state?

A

a description of health that combines info about symptoms, effects on functioning and level of severity

78
Q

What is the ICER?
- current trx costs £2000 over the remaining lifetime of the typical pt which is 10 years. Their utility over that time is 0.7

  • new trx is £22,000, extends life to 11 years and increases utility to 0.75
A

incremental cost = 22,000-2000 = £20,000

current trx QALYs = 0.7 x 10 = 7

new trx QALYs = 0.75 x 11 = 8.25

incremental QALYs = 8.25 - 7 = 1.25

ICER = 20,000/1.25 = £16,000 per QALY gained

79
Q

how does the media report on NICE decisions?

A
  • tend to report patients who’ve benefited from the trx
  • doesn’t report the safety aspects of the new trx
  • sensationalist language, military metaphors etc
80
Q

the time trade off method involves…

A

trading off between length of life and QoL

81
Q

what is meant by the concept of ‘opportunity cost’

A

the health benefits for patients that will be forgone if a new treatment is funded

82
Q

What is a label?

A

They name and describe things

83
Q

Give an example of a label

A

Diagnosing a disease

84
Q

Name some potentially negative consequences of a diagnosis

A
  • psychiatry
  • sick notes
  • legal claim making
  • labels with social, moral and financial consequences
85
Q

What is stigma

A

A negative response to the label

86
Q

What is Goffman’s definition of stigma

A

About identity gone wrong

87
Q

Greek origin of stigma

A

Greek origin: bodily signs cut or burnt into the body designed to expose the bearer as a slave, criminal or social outcast

88
Q

Goffman’s origin of stigma

A

Bodily signs designed to expose something unusual and bad about the moral status of the signifier

89
Q

What is the opposite of stigma

A

Normal

90
Q

What are the political consequences of someone who is stigmatized

A
  • citizenship and lack of entitlement
  • the bearer is culturally unacceptable or inferior
  • associated with shame or disgrace
91
Q

Where does the stigma reside?

A

1) in the person
2) in the audience/observer
Goffman: in the relationship between the attribute and the audience

92
Q

Name 3 categories of stigma described by Goffman

A

1) abominations of the body (stigmas in the body) such as blemishes or deformities
2) character defects (stigmas if character) such as mentally ill or the criminal
3) tribal stigma (social collectives) such as race, religion

93
Q

What is felt stigma

A

the subjective feeling of stigma and being ‘less than normal’ and the fear that one will be treated differently

94
Q

Give an example of research on the difference between felt and enacted

A

Hidden distress modem if epilepsy in Britain (Scambler 2004)

The fear of stignatization us more disruptive than enacted discrimination

95
Q

What is the difference between discreditable and discredited

A

Discreditable - if it were known it would spoil our identity, someone vulnerable to being discredited. For e.g someone with a mastectomy or ileostomy

Discredited - negative judgements for e.g. someone with an amputation or who is in a wheelchair

96
Q

What can weight stigma lead to in children?

A
  • bullying
  • impacts socialising
  • impacts academic performance
97
Q

What can weight stigma lead to in adults?

A
  • employment
  • health
  • the likelihood of engaging in pro health behaviours
98
Q

What is one of the main reasons for weight stigma

A

Attributing blame to the individual

99
Q

what is enacted stigma?

A

when others react differently towards you because of your difference.

Can result in discrimination when you are treated differently to the general population based upon a perceived difference

100
Q

In terms of the swiss cheese model of accident causation, what are latent conditions?

A

Latent conditions include contributory factors that may lie dormant until they contribute to an adverse event/accident

101
Q

In terms of the swiss cheese model of accident causation, what are active failures?

A

Active failures represent unsafe acts directly linked to an adverse event/accident, such as administration of the incorrect drug to the patient

102
Q

what are system barriers

A

help to identify and prevent potential adverse events/accidents. e.g. verbally checking the drug to be administered

103
Q

what is system design

A

refers to designing barriers and safeguards to reduce the potential for errors and adverse events.

104
Q

what is the patient safety alert

A

an example of a strategy for communicating safety critical information and guidance.

105
Q

give examples of information technology for patient safety

A

electronic prescribing and alerts

106
Q

what is the three bucket model intended for?

A

to help staff undertake an individual risk assessment in everyday clinical situations, by considering the self, context and task in each situation

107
Q

what can simulation training do

A

help in practicing individual clinical skills and team working

108
Q

what is a care bundle

A

brings together a related set of evidence based practices

109
Q

what is the safety huddle

A

a short multidisciplinary team briefing

110
Q

lack of intrinsic factor caused reduced absorption in which vitamin?

A

B12

levels of intrinsic factor decrease with age

111
Q

Digital professionalism

define professionalism

A

expectations of conduct extend beyond the workplace

work is connected to identity

112
Q

Digital professionalism

expectations of conduct

A

most employers have standards whilst employees are at work

outside work, usually limited to not bringing the company into disrepute and criminal or grossly offensive conduct

in medicine, the standard of conduct is the same in work and out of work

113
Q

Digital professionalism

what are the problems of digital communication

A
  • sharing, saving: digital is forever and easily shared with anyone. Always recoverable + used against us
  • content: can message without fact checking; confidentiality; reply to all
  • tone:
  • haste
  • response expectation
114
Q

Digital professionalism

when can you send confidential stuff

A
  • NHS mail
  • FAX machine
  • Whatsapp but be careful
115
Q

Difficult conversations

common syndromes defined by symptoms with negative tests

A
  • Fibromyalgia, Chronic Pelvic Pain
  • IBS
  • Tension type headache
  • chronic fatigue
  • non-cardiac chest pain
  • non epileptic seizures
  • functioning neurological disorder
116
Q

Difficult conversations

what is a symptom

A

physical sensation indicating actual or threatened disease

117
Q

Difficult conversations

components of symptom disorders

A
  • past + current cognitive + emotional responses
  • central sensitisation perceptual dysregulation
  • disordered interoception
  • low grade inflammation, microbiome
  • descending pathways: autonomic nervous system, cytokines, HPA axis
118
Q

Difficult conversations

what are the 2 types of reassurance

A

affective and cognitive

119
Q

Difficult conversations

what is affective reassurance

A

engaging emotions
alliance building
validation
generic reassurance

120
Q

Difficult conversations

what is cognitive reassurance

A

shared explanation
specific safety netting
anticipating and empowering

121
Q

Difficult conversations

what theories and models are there for persistent symptoms

A
  • central sensitisation

- dissociation

122
Q

Phases of clinical trial

what is phase 0

A

Testing a low dose of the treatment to check it isn’t harmful

(10-20ppl)

123
Q

Phases of clinical trial

what is phase 1

A

Finding out about side effects, and what
happens to the treatment in the body

(20-50ppl)

124
Q

Phases of clinical trial

what is phase 2

A

Finding out more about side effects and looking at how well the treatment works

(sometimes >100)

sometimes randomised

125
Q

Phases of clinical trial

what is phase 3

A

Comparing the new treatment to the standard treatment

100s or 1000s of ppl

randomised

126
Q

Phases of clinical trial

what is phase 4

A

Finding out more about long term benefits and side effects

variable number of ppl

not randomised

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