PUBLIC HEALTH Flashcards
What is Mental Health as a Definition?
“a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.
What are some Specific mental health problems in doctors?
Increased suicide rates
Increased marital dysfunction and divorce
Increased drug and alcohol problems
What are the symptoms of burnout?
o Diminished personal contact
o Work avoidance
o Increased minor illness
o Feelings of fatigue
What categories can influence health?
o Biological
o Personal lifestyle
o Health services
o The Physical and Social Environment
What is the Black Report 1980?
o Confirmed that social class health inequalities had a big part in overall mortality
o Confirmed health inequalities are widening
o Mechanisms to explain why:
▪ Artefact, social selection, behaviour, material circumstance
What is the Acheson Report 1988?
o Mortality has decreased in the last 50 years but inequalities remained or widened
o Recommendations:
▪ Evaluate all policies likely to affect health in terms of the impact on inequality
▪ Prioritise health of families with children
▪ Government should reduce income inequalities and improve living
conditions in poor households
What is the prevention paradox
Outlines that large numbers of people must participate in a preventive strategy for direct benefit to relatively few.
eg everyone wears seatblets, but only gonaa actually beenfit the small number of people that get in car crashes
What are the 3 doman of publinc health
health improvement - (tackling inequalities)
Health protection (controlling infectious diseases)
Improving services (eg Audits)
What are the Theories of Causation?
Lifecourse
Psychosocial
Materialist
What are some Theories of Causation?
- Lifecourse:
▪ Critical periods have a greater impact in the life course e.g. measles in pregnancy
▪ Accumulation: hazards and their impacts add up e.g. hard blue-collar work
▪ Interactions and pathways - Psychosocial
▪ Social inequality may affect how people feel which in turn can affect body
chemistry, focuses on the individual - Materialist
▪ Poverty exposes people to more health hazards
▪ Disadvantaged people are more likely to live in areas exposed to harm e.g.
damp and pollution
What must consent be?
Consent must be:
o Voluntary
o Informed
o Made by someone with capacity
When is a patient unable to make a decision?
If the Px cannot:
o Understand the relevant information
o Retain it
o Use or weight it to make a decision
o Communicate the decision
What are some Risk factors for CHD?
o Unmodifiable = age, sex, ethnicity, genetics
o Lifestyle: smoking, diet, physical inactivity
o Clinical RF: hypertension, lipids, DM
o Psychosocial: behaviour trait, depression/anxiety, work, social support
What are Coronary Prone behaviours and who described them?
Friedman and Rosenman 1959:
o Competitive, hostile, impatient
o Type A behaviour
o Assess type A behaviour with MMPI
What do the Whitehall Studies show?
o Whitehall I:
▪ Male british civil servants over 10yr period
▪ Men in lowest grade had higher mortality than men in highest grade
▪ 3x mortality rate from all causes
o Whitehall II:
▪ 10,000 civil servants
▪ Employment grade was strongly associated with work control and demands
What is required to verify death?
o No heart sounds or carotid pulse for one minute
o No breath sounds or respiratory effort for one minute
o No response to painful stimuli
o Pupils are fixed and dilated
Define Palliative Care?
Improves QOL of patients and families who face life threatening
illness.
Provides pain and symptom relief and spiritual and psychological support from diagnosis to the end of life and bereavement
Who are some providers of Palliative Care?
o Consultants in palliative medicine
o Clinical nurse specialists e.g. Macmillan nurses
o Social workers
o Chaplains
o Physiotherapists
o Dieticians
What are the building blocks of Palliative Care?
o Holistic
o Individualised
o Patient and family centred
o Multidisciplinary approach
What are the aims of Palliative Care?
o Promote QOL
o Promote dignity and autonomy
o Control disease symptoms
How can you keep alcohol related harm risks low?
o Do not regularly drink >14 units / week
o If you do drink 14 units spread them evenly over 3+ days
o It’s a good idea to have several alcohol-free days each week
What are factors that suggest substance misuse?
o Results in failure to fulfil role obligations e.g. work, school, home life
o May be physically hazardous e.g. driving or operating machinery
o Continued misuse despite persistent or recurrent social or interpersonal problems
How do you calculate the number of alcoholic units in a drink?
- Number of units in a drink = (%ABV x volume in ml)/1000
8g of pure alcohol or 10ml
Define what 1 pack year is
How many straights is in a standard pack of cigarettes?
1 pack year =
1 pack, every day, for a year
its a way of gauging how much someone has smoked over their life
There are 20 cigarettes are in a standard pack of cigarrarettes
Define Dependence?
o a state in which an organism functions normally only in the presence of a drug
o Manifests as a physical disturbance when the drug is withdrawn
Define Tolerance?
o A state in which an organism no longer responds to a drug
o A higher dose is required to achieve the same effect
What are the effects of Alcohol on the CNS?
o Potentiates GABA (inhibitory neuroT in the CNS)
o Inhibits Glutamate (excitatory neuroT in the CNS)
Outline the Pharmacokinetics of Alcohol?
o Absorption:
▪ Well absorbed at small intestine.
▪ Highly lipophilic
▪ Absorption is age related and can be delayed in the elderly
▪ Half life 6 – 30 hrs.
▪ Highly protein bound
o Distribution and metabolism:
▪ Extensively metabolised by the liver.
▪ Crosses BBB
▪ Particularly active in CNS ‘grey matter’ (high blood flow)
o Elimination:
▪ Excreted in the urine mainly in the form of its metabolites.
▪ Excreted as conjugates (glucuronide or sulphate).
▪ Nil biliary excretion.
How is Wernicke’s Encephalopathy Treated?
Treated with Pabrinex, (and thiamine)
How is Alcohol Withdrawal Treated?
TREAT WITHDRAWAL WITH BENZODIAZEPINES
What is the Primary Prevention to control STIs in the community?
o Primary prevention = reducing the risk of acquiring STI
▪ Awareness campaigns e.g. “Sex. Worth talking about”
▪ Vaccination e.g. HBV, HPV
▪ One to one risk reduction discussions
▪ “keys cash condom” poster
▪ Pre and post exposure prophylaxis
What are some Secondary Control Strategies to control STIs in the community?
o Secondary prevention = find and treat undetected cases of infection
▪ Easy access to STI/HIV tests/treatment
▪ Partner notification (contact tracing)
▪ Targeted screening:
* Antenatal screening for HIV and syphilis
* National chlamydia screening programma
* HIV home testing kds
What are some Tertiary Preventions of STIs?
o Tertiary prevention = reducing morbidity / mortality
▪ Antiretrovirals for HIV
▪ Prophylactic ABX for PCP
▪ Acyclovir for suppression of genital herpes
What are some complications of STIs in Women?
o Pelvic inflammatory disease
o Ectopic pregnancy
o Infertility
o Neonatal transmission
Why do some populations/religions carry out Female Genital Mutilation (FGM)?
o Seen as being ‘pure’
o Unable to marry without it being performed
What are complications of FGM?
o Bleeding
o Wound infection incl. tetanus, HIV, HBV
o Pain, death
o LUTS, period problems
o Anxiety
o PTSD
o Withdrawal
What are some Infective conditions that Migrants may present to their GP with?
o Hepatitis viruses
o TB
o Malaria
o HIV
o Parasitic infections
What are some mental health problems that War Refugees may Suffer with following immigration?
o PTSD
o Depression
o Suicidal thoughts, anxiety
o Somatisation e.g. chronic pain, dizziness, chronic fatigue, headache
What are some signs for Occupational Asthma?
o Typical history = improve away from work / when on holiday
o Peak flow diary
o Look for a dip of >20% when at work
o Workplace challenge testing
What are some Problems with Teamwork?
o Lack of teamwork
o Lack of leadership
o Lack of effort
o Lack of communication
o Lack of challenge
What is SBARR Communication?
o Situation
o Background
o Assessment
o Recommendation
o Response / review
Outline the tradition hierarchy of evidence, form top to bottom - it ranks how reliable different types of study design are
Systematic reviews/metanalysis
Randomised control trail
Cohort studies
Case control studies
Case series/reports
What is a meta analysis?
examination of data from a number of independent studies of the same subject, in order to determine overall trends.
” a study of studies”
What Do Antigenic Drift and Shift Cause?
- Antigenic drift → seasonal epidemics
- Antigenic shift → pandemics
What is the difference between an outbreak, Epidemic and Pandemic?
- Outbreak = 2+ linked cases
- Epidemic = more cases in a region or country
- Pandemic = spans international boundaries
What is the characteristic presentation of Influenza?
Influenza characterised by upper and lower RT symptoms + fever, headache, myalgia, weakness
What are the risk factors for Drug Use and Misuse?
o Quantity and frequency of use
o Knowledge of what they’re using e.g. strengths, purity etc
o Poly drug use
o Propensity for risky behaviour
o Co – existing problems e.g. mental and physical health, housing, employment, family
What are some side effects of drug misuse?
o Overdose and temporary psychotic states, unpredictable behaviour
o Sudden pyrexia, tachyC, coma
o Hallucination and vomiting
o Aggression and violence
o Intense comedown
What are some family risk factors for Drug Abuse?
o FHx of substance misuse
o Family management problems e.g. poor parenting
o Family conflict / domestic abuse
o Being in care
What are some Social/Community Risk factors for Drug Abuse?
o Low academic attainment and commitment
o Availability of drugs
o Community norms favourable to drug use
o Community disorganisation
o Transitions / mobility
o Low neighbourhood attachment
What are some individual Risk factors for Drug Abuse?
o Risk taking
o Rebelliousness
o Friends who use drugs
o Experience of trauma e.g. abuse, loss, poor parenting
What is Physical Dependence?
o The body adapts to presence of the substance and over time needs more for the same effect (tolerance)
o Stopping leads to withdrawal symptoms e.g. stomach cramps, muscle aches
What is Psychological Dependence?
o Feeling that life is impossible / challenges cannot be faced without the drug
o Emotional effect: feelings of fear, pain, shame, guilt, loneliness if not on drug
What are the features of the National Drug Strategy 2017?
o Reduce demand
o Restrict supply
o Building recovery in communities
o Family / community involvement
o Payment by results
o Abstinence focused with emphasis on recovery and peer support
What is the Alcohol Harm Paradox?
- Alcohol harm paradox: research suggests that low SES groups drink less alcohol than high SES groups but experience more alcohol related harm
What is a risk if pregnant women drink alcohol?
Foetal Alcohol Syndrome:
o Pre and post-natal growth retardation
o CNS abnormalities e.g mental retardation, irritability, incoordination, hyperactivity
o Craniofacial abnormalities
o Defects of eyes, ears, mouth, CVS, GUT, skeleton
What are the Signs and Symptoms of Alcohol Withdrawal?
o Tremors (‘the shakes’)
o tachycardia
o Hypertension
o Seizures
o Hallucinations
o Delirium
What are the Chronic effects of Alcohol Excess?
o Dementia
o Cerebellar degeneration
o Fatty liver
o Cirrhosis
o Liver cancer
o HTN, CHD
What are the Psychosocial Effects of Excessive Alcohol Consuption?
o Violence, rape, depression or anxiety
o Problems at work
o Criminality
o Social disintegration / poverty
o Driving incidents/offences
What are some Primary Prevention Strategies for Alcohol Excess?
o ‘Know your limits’ binge drinking campaign
o Drinkaware alcohol labelling
o ‘THINK!’ drunk driving campaign
o Restriction on alcohol advertising by Ofcom
o TV ad campaigns
o Minimum pricing
What are some Screening tools for Alcoholism?
CAGE Questions:
Have you ever been told you should CUT down how much you drink?
Have you ever been ANNOYED by people telling you to Cut down?
Have you ever felt GUILTY about how much you drink?
EYE OPENER - Have you ever had a drink first thing in the morning/ to settle yourself
Types of screening - outline the Seedhouse ethical grid
The Seedhouse grid is an ethical tool used by healthcare professionals to consider possible. actions to take when faced with a difficult situation.
It helps one explore the dilemma and. competing interests
Consits of four layers, each look at 4 difference categories of issues
Outline the first 2 inner layers of the seedhouse ethical grid
1st - whether the intervention is going to create autonomy, respect autonomy and treat all equally?
2nd - Duties and motives. Is the intervention consistent with moral duties; keeping promises, telling the truth, minimising harm and maximising benefit?
Outline the second outer 2 layers of the seedhouse ethical grid
3rd - Consequentialist layer. Is the intervention going to provide the greatest benefit for the greatest number? Who will benefit, society, individuals, a group?
4th Is the intervention likely to be affected by external considerations e.g. risks, law, use of resources
AMCL
What are the headings which make up the four quadrants approach to clinical ethical analysis?
Medical indications.
Patient preferences: respect for autonomy.
Quality of life.
Contextual features.
MP QC
What are some Notifiable Diseases to PHE?
o Acute encephalitis
o Acute meningitis
o Acute infectious hepatitis
o Anthrax
o Cholera
o Legionnaires disease
o Malaria
o Measels
o SARS
o Smallpox
o TB
Why is Diabetes a Public Health issue?
o Mortality: common underlying cause of death
o Disability: blindness, renal failure, amputation etc.
o Co-morbidity: other physical and mental health conditions
o Reduced QOL
Why is Diabetes on the rise?
o Sedentary job, sedentary leisure activities
o Diet high in calorie dense food/low in fruit and veg, pulses and wholegrain
o Obesogenic environment
▪ Physical e.g. TV remote, lifts, car culture
▪ Economic e.g. cheap TV watching, expensive fruit and veg
▪ Sociocultural environment e.g. safety fears, family eating patterns,
What are factors that Maintain Obesity?
o Physical / physiological: more weight = more difficult to exercise e.g. arthritis, stress incontinence
o Psychological = low self esteem and guilt, comfort eating
o Socioeconomic: reduced opportunities, employment, relationships, social mobility
What is primary prevention of obesity?
o Sustained increase in physical activity
o Sustained change in diet
o Sustained weight loss
What are some diabetes Screening tests?
o Random capillary blood glucose
o Random venous blood glucose
o Fasting venous blood glucose
o Oral glucose tolerance test
o HbA1c
What are some factors affecting Patient Compliance?
o Socioeconomic e.g. long distance from treatment setting
o Health system e.g. supply of medication
o Condition e.g. memory impairment
o Therapy e.g. complex treatment regimes
o Patient e.g. disbelief / denial of diagnosis
When Can Confidentiality Be Broken?
o They are a risk to the public e.g. intend to commit a crime
o If they have given conseerrnt
o If it is required by law e.g. notifiable disease, ordered by a judge
What is Anorexia Nervosa?
o Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, developmental trajectory and physical health
What are some thought processes of Px with Anorexia Nervosa?
o Intense fear of gaining weight or becoming fat, even though underweight
o Undue influence of body weight/shape on self esteem
o Denial of the seriousness of the current low body weight
o May be restricting or binge eating / purging subtype
What is Bulimia Nervosa?
o Recurrent episodes of binge eating characterized by both of:
▪ Eating in a discrete amount of time large amounts of food
▪ Sense of lack of control over eating during an episode
o Recurrent inappropriate compensatory behaviour to prevent weight gain (purging)
What is Binge Eating Disorder?
o Recurrent episodes of binge eating, episodes associated with 3+ of the following:
▪ Eating much more rapidly than normal
▪ Eating until feeling uncomfortably full
▪ Eating large amounts of food when not feeling physically hungry
▪ Eating alone because of feeling embarrassed by how much one is eating
▪ Feeling disgusted with oneself, depressed or very guilty afterwards
What are some Risk factors for eating disorders?
non-specific:
genes,
temperament,
family interaction,
social pressure,
trauma
What is important to look out for in Px with Eating Disorders?
o Severe restriction of food/fluid
o Electrolyte imbalance
o Bone deterioration
o Physical damage e.g. oesophageal tears, blood in vomit
o Alcohol/drug taking
What are some urgent signs of Eating disorder damage?
o Muscular weakness
o Problems in breathing
o Deterioration of consciousness
o Cardiac signs e.g. tachyC, bradyC, hypoT
o Rapid weight loss, risky behaviours
What are some treatments for Eating Disorders?
o CBT, family therapy, specialist support
What is the chain of Transmission?
Host → person to person spread → reservoir (soil, water, people) → portal of exit (coughing faeces) → agent → mode of transmission → portal of entry → host
What is the second leading cause of death among children under 5 globally?
Diarrhoea
What should you do if you suspect a C. diff infection?
SIGHT
o Suspect C. diff as a cause of diarrhoea
o Isolate the cause
o Gloves and apron
o Hand washing
o Test stool for toxin
Where are Norovirus Outbreaks common?
o Schools
o Cruise ships
o Restaurants
o Hospitals
What are the 2 main types of back pain?
May be simple (mechanical) or nerve root (neurological)
What is the Epidemiology of Simple Back Pain?
Simple back pain presents between 20-55, normally lumbrosacral, pain is mechanical in nature, 90% recover from acute attacks within 6/52
What is the Epidemiology of Neurological Back Pain?
o Numbness or paraesthesia can accompany pain, reflex changes
o 50% recover from acute attack within 6 weeks
o Red flags: very old or young, violent trauma, constant/progressive pain, systemic upset, widespread neurology, structural deformity
What proportion of adults are obese?
2/3rds
What are some physical Effects of Obesity?
o High cholesterol and blood pressure
o Pre-diabetes
o Bone and joint problems
o Breathing problems
o Risk of premature mortality
o RF for heart disease, stroke, cancer, liver disease, infertility, depression, sleep
apnoea, asthma, DM
Who is at higher risks of Obesity?
More common among people from more deprived areas, older age groups, disabled people
What are some social interventions to lower obesity?
o Wider level e.g. change4life, 5-a-day
o Environment e.g. more cycle paths, less car parking
o Public policy e.g. sugar tax, minimum alcohol pricing
What is Patient Centred Medicine?
Patient centred care encourages focus on the patient as a whole and shared control of health decisions, better compliance and health outcomes
What are the key principles of Patient Centred Medicine?
o Improve communication
o Increase patient understanding
o Understand patient perspective
o Provide information
o Assess adherence
o Review medication regularly
How must consent be obtained?
- Consent must be voluntary, informed and made by someone with capacity
- Patients must be told what a treatment is, how it’s done, risks, benefits and alternatives
o Proper consent reduces negligence claims
What is Human Error?
A failure of a planned action or a sequence of mental or physical actions to be
completed as intended, the use of a wrong plan to achieve an outcome
Outline the types of error
Omission - didn’t do something that needed to be done
Commission - doing something actively bad
Negligence - done the action needed, but not to the right standard
Skill based - doing something beyond your capabilities
What is the Swiss Cheese Model of Error?
o Each slice is a level of defence, holes are latent conditions/poor design/poor
management decisions
o If many holes line up it gives a patient safety incident
o Examples of level defence:
▪ Checking drugs before administration
▪ Preop checklist
▪ Marking surgical site before operation
Describes 1 problem - if the holes align - the it leads to another/major incident
What are Never Events?
o Serious largely preventable patient safety incidents
o Should not occur if the available preventative measures have been implemented
o Intolerable and inexcusable
Give some examples of Never Events?
▪ Wrong site at surgery
▪ Wrong implant
▪ Retained object in surgery
▪ Overdose of serious drugs
How long into pregnancy can abortion take place?
Abortions generally can take place until 24 weeks of pregnancy
o May take place later e.g. if there’s a risk to life or problems with the baby’s
development
What is Compliance?
The extent to which the patient’s behaviour coincides with medical or health advice
What are the disadvantages of compliance?
▪ It is passive: the patient MUST follow the doctor’s orders
▪ It assumes the doctor knows best
▪ It ignores problems patients have in managing their health
What is Adherence?
The extent to which the patient’s actions match agreed recommendations, more patient centred
What are the key principles of Adherence?
▪ Improve communication
▪ Increase patient involvement
▪ Understand the patient’s perspective
▪ Provide and discuss information
▪ Assess adherence
▪ Review medicines
What is Concordance?
Expectation that patients will take part in treatment decisions and have a say in the consultation, it is a negotiation between equals
What are some barriers to Concordance?
▪ Patient may not want to engage in discussions with their doctor
▪ May lead to worry
▪ Patients may just want the doctor to tell them what to do
▪ Time, resources, organisational constraints
▪ Challenging, patient choice may differ significantly from medical advice
What are the advantages of good doctor patient communication?
o Better health outcomes
o Higher compliance to therapeutic regimens
o Higher patient and clinical satisfaction
o Decrease in malpractice risk
What are some barriers to Good communication?
o Language barriers
o Deafness / blindness
o Medical jargon
How can Endogenous Infections be prevented?
o Good nutrition and hydration
o Antisepsis
o Control underlying disease
o Remove lines and catheters
o Reduce antibiotic pressure e.g. short courses
What can cause delerium?
UTI
Opiates
Alcohol Withdrawal
Hypoglycaemia
Hypoxia
What are some features of Delerium?
o Acute onset
o Impaired attention
o Decreased consciousness
o Usually reversible
o Often accompanied by physical illness
o Hospital acquired
What is the WHO definition of health
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
What is the biopyschosocial model of health?
Who
The biopsychosocial model of wellness and medicine examines how the three aspects – biological, psychological and social – occupy roles in relative health or disease. The BPS model stresses the interconnectedness of these factor
What is the biomedical model of health?
Health is merely the state of no disease
Outline the 4 elements of the sick role
(1) exemption from normal social role responsibilities,
(2) the privilege of not being held responsible for being sick,
(3) the desire to get better and
(4) the obligation to find proper help and follow that advice.
What do you need to consider when someone taking long term steroids is sick?
Sick day rules are really important in anyone taking long term steroids -
patients must double the dose when they are sick!
What is primary prevention
Stopping disease happenig in the first place
What is secondary prevention
Stopping something before symptoms start
(pre clinical)
eg taking statin for high BP
What is tertiary prevention
Stopping clinical disease from getting worse
What are the 4 types of risk factors
Lifestyle (eg smoking)
Clincial (high BP)
Enviromental (air pollution)
Physcosocial (stress, insecrue job)
Ethics: what are the 4 principles?
Autonomy - respect the patient’s choices. (deontological)
Beneficence - do good. (Utilitarian)
Non-maleficence - do no harm. (Deontological)
Justice. (Utilitarian)
Ethics: what is deontology?
Features of the act determines worthiness. Deontology teaches that acts are right or wrong, people have a duty to act accordingly. Do unto others as you would be done by.
Ethics: categorical imperatives are a type of deontology. What are categorical imperatives?
A rule that is true in all circumstances. You should act in such a way that you would be willing for it to become universal law that everyone follows in the same situations.
What are the challenges of deontology?
Consequences aren’t looked at.
2. Duties can conflict.
What are virtue ethics?
Virtue ethics focus on the character of the person acting, are they integrating reason and emotion? An act is only virtuous if the person has the right mind set/intentions. Virtues are acquired.
What are the challenges of virtue ethics?
Virtue ethics don’t focus on consequences. They are culture specific and too broad for practical application. It’s not always clear how to solve a moral dilemma using virtue ethics.
describe positive predictive value?
Proportion of positive results that are true positives
Describe Negative predictive value
proportion of negative results that are true negatives
What are utilitarian ethics (consequentialism)?
An act is evaluated solely in terms of its consequences. Maximise good and minimise harm.
What are the challenges of utilitarian ethics (consequentialism)?
Treats minorities unfairly to promote the happiness of a majority.
What are the driving rules for
TIA
Syncope
Seizure
TIA - Do not need to inform DVLA - One month
First unprovoked seizure, no abnormalities - 6 months
Syncope - don’t drive for 6 months
Known epileptic Seizure -12 months since last seizure
Define case control study
Patients who have developed a disease are identified and their past exposure to suspected aetiological factors is compared with that of controls who do not have the disease
PAST
Define RCT
A study in which people are randomly assigned to 2 (or more) groups to test an intervention. One group has the intervention being tested, the other has an alternative intervention or no intervention at all. The groups are followed up to see how effective the experimental intervention was
Define cross sectional study
Where you collect data from many different individuals at a single point in time. You observe variables without influencing them. AT PRESENT
Define cohort study
A type of epidemiological study in which a group of people with a common characteristic is followed over time to find how many reach a certain health outcome of interest - FUTURE
If a person’s absolute risk of heart attack is 0.3 without treatment and drops to 0.25 with treatment, what is their
a) absolute risk reduction?
b) relative risk reduction
Absolute risk reduction = absolute risk of events in the control group –
absolute risk of events in the treatment group. 0.3-0.25 = 0.05 = 5%
Relative risk = 0.3 - 0.25 = 0.05
0.05/0.3 = 0.1667, or 16.7
