Public health Flashcards
what are the types of harms with primary medicine of abuse (the main ingredient)
- addiction: benzo, opiates
- follow-on abuse: alcohol, illicit drugs
- electrolyte imbalance: laxatives
- withdrawal syndrome: SSRIs
- convulsions/acidosis: chlorphenamine, antihistamine
what are the types of harm in the additional ingredient?
- GI (indigestion bleed, death): ibuprofen
- Hypokalaemia + acidosis: ibuprofen
- Hepatotoxicity, death: paracetamol
- rebound headache: paracetamol
why is there a problem for both OTC and prescription drugs?
- 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
what are the range of treatments and strategies used?
- formal addiction services
- self-help
- involvement of GP
- online support
- Narcotics Anonymous
- private clinics
Name some prescription medicines associated with abuse + dependency
- opioids
- benzodiazepines
- Z-drugs (zopiclone, zolpidem)
- SSRI antidepressants (fluoxetine
- GABAergics (gabapentin, pregabalin
Name some OTC medicines associated with abuse and dependecy
- analgesic codeine w/ paracetamol
- opiate cough medicines (codeine linctus)
- sedative antihistamines (sleep)
- laxatives
- nicotine replacement therapy
- decongestant stimulants
Risk factors for addiction on OTC medication
- genetic
- personal psychosocial profile
- personal or FH of addiction
- psychiatric disorders
what is the addict identity
- drug seeking behaviour
- withdrawal
- loss of control
- use for different effect
- few treatment options
what is the perceived stereotypical addict identity?
- chaotic
- illicit substance
- alcohol misuse
- treatment options
- appearance
what is the professional identity?
- intelligent
- knowledgeable
- respectable appearance
what attempts have been done to manage/reduce OTC abuse?
- pharmacy- based (hide products, refuse sales, record sales)
- harm reduction intervention pilot (GP referral)
- proposed contract/reduction scheme in pharmacies
what is the revised advice on OTC codeine sales
- 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)
what did the All party parliamentary group (APPDMG) recommend for OTC addiction?
Increased:
- training for Drs, nurses, AHPs
- awareness of problem
- recognition/support for online help
- info to patients about risks
Name a prescription abuse and addiction strategy
Royal College of GP created 4 factsheets
what did the Royal College of GPs focus on their 4 factsheets
- 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
name other approaches for prescriptions and OTC problems
- internet support groups; FRANK, mumsnet, overcount
- social media
NHS imporvement strategy
maximises the things that go right and minimise what goes wrong
What is the systems approach
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.
eg of a system failure
Wayne Jowett died at 18 after cytotoxic drug, vincristine, intended for IV was instead injected into his spine
strategies to minimise risk
- 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
name 2 System designs
hard defences: engineered safety defences
soft defences: people + systems
name an example of a hard defence
ATM machine redesigned so users don’t forget their card in the machine
What was the result of the Wayne Jowett case?
Patient safety alert: spinal and LP connectors cannot connect with IV connectors or spikes
example of simplification and standardisation of clinical processes
- checking drugs and identity prior to administration of medication
- marking a surgical site before an operation
- SBAR (situation, background, assessment, recommendation)
example of standardised observation
national early warning score
examples of checklists and protocols
- surgical safety checklist
- emergency department patient safety checklist
what do you need to balance with a checklist
requirement to take action vs requirement to use cognition.
Little time to think and use the checklist allows immediate structured action
emergency department patient safety checklist
outlines the clinical tasks needed to complete in the first few hours in their admittance to ED
examples of information technology
- electronic prescribing
- computerised alerts
- electronic risk assessment for VTE
name some disadvantages to information technology
if not fully integrated and implemented well and doesn’t create whole picture of the patient’s medication needs
identify tools to imporve uptake of evidence based trx
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
what is the AMBER care bundle
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
approaches to supporting better team working
- team training: simulation
- safety huddle
what makes a successful safety huddle?
agreed actions
informed feedback of data
personal strategies for mental preparedness
- foresight
2. 3 bucket model
what is foresight
the ability to identify, respond to and recover from the initial indications that a patient safety incident could take place
what is the 3 bucket model
it assesses risky situations
- self: lack of knowledge, fatigue
- context: distractions, lack of time, poor equipment
- task: complex?
the fuller your buckets, the more likely something will go wrong, but your buckets are never empty
define an older person
aged 60 and older
name nutritional concerns of older adults
- change in body composition
- decreased energy requirements
- sarcopenia/obesity
- bone loss
- chronic disease
- monotonous diet
- protein
- B12, B6
- Folic acid
- Vit D
- Calcium
why is energy per kg of body weight reduced with age?
lean body mass and basal metabolic rate decreases with age
what are the main uses of energy?
BMR, physical activity and thermogenesis
what is BMR determined by?
body composition of fat
why do energy requirements decline with age?
lower physical activity and lower BMR
what is the requirement of protein for older adults
- yet to be identified so set to be the same as for younger people (0.5g/kg)
what are the vitamin requirements for older adults?
- vit D at 10ug (400IU)
- older women need more iron
- everything else are practically identical
common causes of iron deficiency anaemia in an older adult
- less iron intake
- GI bleed
define malnutrition
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
causes of malnutrition
- cannot afford food
- cannot prepare food because of physical disability
- loss of appetite
- reduced food intake
- loss of cognition and vision
intervention for malnutrition
- dietary change
consequences of malnutrition
- 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
what is sarcopenia
- a decrease in lean body mass associated with ageing
- may co-exist with obesity: sarcopenic obesity
what are the causes of sarcopenia
- reduced physical activity
- change in body composition
- malnutrition
- increased cytokine production
- reduced sex hormones
- chronic disease
name some psychological and social factors affecting nutritional intake
- isolation
- neglect
- psychological (bereavement, depression, dementia)
- economic
- social support (meals on wheels)
name some phsiological factos affecting nutritional intake
- visual impairment
- mobility
- dexterity - arthritis
- dental health
- illness/polypharmacy
- GI changes (taste, hormonal, CCK< gut motility, atrophic gastritis
assessment of nutritional status in the older adult
- BMI (18.5-25)
- demispan
- height
- waist circumference
- skinfold thickness
why is BMI not accurate
- oedema
- muscle
what is demispan
distance from sternal notch to tip of middle finger in coronal plane
what is a another way to measure body fat
bioelectrical impedance analysis (BIA): lean tissue is a better conductor of electricity
how do you assess physiological function
- hand grip strength
- timed ‘up and go’
- 30 sec chair stand test
what nutritional screening tools are used?
- MUST (Malnutrition Universal Screening Tool)
- MNA (Mini Nutritional Assessment)
What is MUST?
Malnutrition Universal Screening Tool
help detect individuals at risk of malnutrition
0 - no risk
1 - medium risk
2+ - high risk
what is MNA
mini nutritional assessment for for aged 65+
18 Qs scored to determine if at risk of malnutrition
what is economic evaluation?
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
What is QALY?
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
what is ICER
incremental cost-effectiveness ratio
the incremental costs of one trx over another, divided by the incremental effects
what are the two key features of economic evaluation
1) measures cost and outcomes
2) assesses these costs and outcomes for at least two or more trxs
cost-effectiveness analysis
outcomes are measured in natural units (e.g. incremental cost per life year gained)
cost-utility analysis
outcomes are measured in quality adjusted life years (e.g. incremental cost per QULY gained)
cost-benefit analysis
outcomes are measured in monetary units (e.g. net monetary benefit)
cost-minimisation analysis
outcomes (measured in any units) are the same in both trxs.
This is used when the aim is only to minimise costs
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
10,000/10
= £1000 per life year gained
What is PROMs
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
how would you measure benefits of a trx?
- PROMs
- QALY
How to calculate QALY
length of life expected to be gained by the new trx x QoL a patience can expect to have
single QALY
= one year in perfect health
what are the elements required to find the Q in QALY
- describe the health state that is going to be valued
- value the health state described
- need a group of ppl to provide the values
what is the health state?
a description of health that combines info about symptoms, effects on functioning and level of severity
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
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
how does the media report on NICE decisions?
- 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
the time trade off method involves…
trading off between length of life and QoL
what is meant by the concept of ‘opportunity cost’
the health benefits for patients that will be forgone if a new treatment is funded
What is a label?
They name and describe things
Give an example of a label
Diagnosing a disease
Name some potentially negative consequences of a diagnosis
- psychiatry
- sick notes
- legal claim making
- labels with social, moral and financial consequences
What is stigma
A negative response to the label
What is Goffman’s definition of stigma
About identity gone wrong
Greek origin of stigma
Greek origin: bodily signs cut or burnt into the body designed to expose the bearer as a slave, criminal or social outcast
Goffman’s origin of stigma
Bodily signs designed to expose something unusual and bad about the moral status of the signifier
What is the opposite of stigma
Normal
What are the political consequences of someone who is stigmatized
- citizenship and lack of entitlement
- the bearer is culturally unacceptable or inferior
- associated with shame or disgrace
Where does the stigma reside?
1) in the person
2) in the audience/observer
Goffman: in the relationship between the attribute and the audience
Name 3 categories of stigma described by Goffman
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
What is felt stigma
the subjective feeling of stigma and being ‘less than normal’ and the fear that one will be treated differently
Give an example of research on the difference between felt and enacted
Hidden distress modem if epilepsy in Britain (Scambler 2004)
The fear of stignatization us more disruptive than enacted discrimination
What is the difference between discreditable and discredited
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
What can weight stigma lead to in children?
- bullying
- impacts socialising
- impacts academic performance
What can weight stigma lead to in adults?
- employment
- health
- the likelihood of engaging in pro health behaviours
What is one of the main reasons for weight stigma
Attributing blame to the individual
what is enacted stigma?
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
In terms of the swiss cheese model of accident causation, what are latent conditions?
Latent conditions include contributory factors that may lie dormant until they contribute to an adverse event/accident
In terms of the swiss cheese model of accident causation, what are active failures?
Active failures represent unsafe acts directly linked to an adverse event/accident, such as administration of the incorrect drug to the patient
what are system barriers
help to identify and prevent potential adverse events/accidents. e.g. verbally checking the drug to be administered
what is system design
refers to designing barriers and safeguards to reduce the potential for errors and adverse events.
what is the patient safety alert
an example of a strategy for communicating safety critical information and guidance.
give examples of information technology for patient safety
electronic prescribing and alerts
what is the three bucket model intended for?
to help staff undertake an individual risk assessment in everyday clinical situations, by considering the self, context and task in each situation
what can simulation training do
help in practicing individual clinical skills and team working
what is a care bundle
brings together a related set of evidence based practices
what is the safety huddle
a short multidisciplinary team briefing
lack of intrinsic factor caused reduced absorption in which vitamin?
B12
levels of intrinsic factor decrease with age
Digital professionalism
define professionalism
expectations of conduct extend beyond the workplace
work is connected to identity
Digital professionalism
expectations of conduct
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
Digital professionalism
what are the problems of digital communication
- 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
Digital professionalism
when can you send confidential stuff
- NHS mail
- FAX machine
- Whatsapp but be careful
Difficult conversations
common syndromes defined by symptoms with negative tests
- Fibromyalgia, Chronic Pelvic Pain
- IBS
- Tension type headache
- chronic fatigue
- non-cardiac chest pain
- non epileptic seizures
- functioning neurological disorder
Difficult conversations
what is a symptom
physical sensation indicating actual or threatened disease
Difficult conversations
components of symptom disorders
- past + current cognitive + emotional responses
- central sensitisation perceptual dysregulation
- disordered interoception
- low grade inflammation, microbiome
- descending pathways: autonomic nervous system, cytokines, HPA axis
Difficult conversations
what are the 2 types of reassurance
affective and cognitive
Difficult conversations
what is affective reassurance
engaging emotions
alliance building
validation
generic reassurance
Difficult conversations
what is cognitive reassurance
shared explanation
specific safety netting
anticipating and empowering
Difficult conversations
what theories and models are there for persistent symptoms
- central sensitisation
- dissociation
Phases of clinical trial
what is phase 0
Testing a low dose of the treatment to check it isn’t harmful
(10-20ppl)
Phases of clinical trial
what is phase 1
Finding out about side effects, and what
happens to the treatment in the body
(20-50ppl)
Phases of clinical trial
what is phase 2
Finding out more about side effects and looking at how well the treatment works
(sometimes >100)
sometimes randomised
Phases of clinical trial
what is phase 3
Comparing the new treatment to the standard treatment
100s or 1000s of ppl
randomised
Phases of clinical trial
what is phase 4
Finding out more about long term benefits and side effects
variable number of ppl
not randomised
