Public Health 2 Flashcards
What is the ‘Prevention Paradox’?
A preventative measure which brings much benefit to the population offers little to each participating individual.
Give an example of an everyday activity to which the prevention paradox can be applied.
- If everyone wears a seatbelt on every journey, for 1 life saved, there would be about 400 who would always take the preventative precaution of wearing a seatbelt.
The ICD-10 can be used to assess addiction. What behaviours might a person who is addicted to drugs / alcohol exhibit?
- Craving
- Tolerance
- Compulsive drug-seeking behaviour
- Physiological withdrawal state
List some acute physical effects of dependent drug use.
- Complications of injecting -> DVT, Abscesses
- Overdose -> respiratory depression
- Poor pregnancy outcomes
- Side effects of opiate: constipation, low salivary flow
List some chronic physical effects of dependent drug use.
- Blood-borne virus transmission e.g. Hep C
- Effects of poverty
- SE of cocaine: vasoconstriction, local anaesthesia
List some social effects of dependent drug use.
- Effects on families / relationships
- Social exclusion
- Driven to criminality
- Imprisonment
List some psychological effects of dependent drug use.
- Fear of withdrawal
- Craving
- Guilt
- all are temporarily alleviated by drug use.
How does Heroin act?
How is it used?
- Acts at opiate receptors; used 8 hourly
- Routes of administration:
> smoking / snorting
> oral / rectal
> sub cut / IV / IM
What are the effects of Heroin?
- Euphoria
- Intense relaxation
- Miosis (excessive pupil constriction)
- Drowsiness
What are the adverse effects of heroin?
- dependance + withdrawal symptoms
- physical complications -> nausea, itching, sweating, constipation
- over dose :(
How does Cocaine / Crack act?
- Blocks re-uptake of mood-enhancing neurotransmitters at the synapse (serotonin, dopamine)
- Intense, pleasurable sensation
- Reinforcement -> leads to further use
- Depletion at sensory neurone
What are the effects of Cocaine / Crack?
- Confidence, well-being, euphoria, impulsivity, increased energy, alertness
- impaired judgement, decreased need for sleep
What are the ‘negative’ effects of Cocaine / Crack?
- May produce anxiety, hypertension, arrhythmias
- subsequent ‘crash’ -> dysphoria
Chronic effects:
- depression, panic, paranoia, psychosis
- damaged nasal septum
- cerebrovascular accidents
- respiratory problems
What are the aims of treatment for drug users?
- To reduce harm to user, family + society
- To improve health
- To stabilise lifestyle, and decrease the amount of illicit drug use
- Reduce crime
What are the modalities of treatment for drug users?
- Harm reduction
- Detoxification
- Maintenance
- > Methadone = full agonist
- > buprenorphine = partial agonist
- Relapse prevention -> Naltrexone
- Psychological interventions
- Referral for allied problems (Hep C, STIs, etc.)
What can I offer a newly presenting drug user?
- Health check
- Screening for blood borne viruses
- Contraception, smear
- Sexual Health Advice
- Check general immunisation status
- Sign post to additional help
- Information on local drugs services, including needle exchange
You are an F1 + you need to do a quick assessment of a newly presenting drug user.
What 6 questions should you ask?
1, Which drug?
- Route of administration?
- How long have they been addicted?
- What is the patient’s goal
- quick detox -> good outcomes in new users
- slow reduction / maintenance - Does the patient need a referral?
- eg. pregnancy, severe psychiatric co-morbidity, Hep C positive - Does the patient require interagency working / specialised support?
- child protection issues
- housing problems etc.
What are the 3 levels of Basic Harm Reduction (as applied to drug users).
- Action to prevent deaths
- Action to prevent blood borne virus transmission
- Referral where appropriate.
Who might be suitable for quick detoxification (as applied to drug use)?
- Young user
- Less time addicted
- Often not injecting
- Lower level of drug use
What medication(s) might you use for quick detoxification (of drug use)?
- Buprenorphine is 1st line
> Lofexidine in very young / very low level use - Other symptomatic medication
- Support from other agencies + teams
Following drug use, who might be suitable for ‘Stabilisation + Maintenance’?
- Opiate user
- Longer time addicted, usually injecting
- May be high levels of drug use
What is the aim of ‘Stabilisation + Maintenance’ following drug use?
How is the medication used?
- Harm minimisation
- Use methadone or buprenorphine
- Titrate from a low starting dose to a maintenance dose.
- Keep people alive until they are ready to become abstinent
What is the aim of treating a person who is using crack cocaine?
- Harm reduction is key -> no substitute meds are available
- advice on safe sex / contraception / blood borne virus advice - Brief Intervention
- explanation of effects / risks
- setting limits
- cognitive based approaches - Team working
- Refer to Sexual Health / Infectious Diseases
- Referral for specialist advice, if appropriate
What is involved in drug relapse prevention?
- Naltrexone tablets are licensed
> check LFTs, Urinalysis
> warnings regarding concomitant heroin use - MDT approach = essential
- Constantly relapsing patients may need stabilisation + maintenance to avoid ‘revolving door’
What considerations should you have when a drug user comes into hospital?
- may be very ill
- may be craving drugs, esp. opiates
- may fear a negative response from staff
- may already be prescribed maintenance medication (needs to be continued)
- may be untreated and will need to start treatment if they are to stay in hospital
- liaison between community + hospital prescribers on admission + discharge
What are the recommended alcohol intake levels for men and women?
14 units / week
What is the guidance for alcohol consumption during pregnancy?
- Abstain for 1st trimester
- No more than 2 units / week in the 2nd and 3rd trimesters
What is ‘hazardous drinking’?
- Pattern of alcohol use which increases someone’s risk of harm
What is ‘higher risk drinking’?
Men: 50+ units / week
Women: 35+ units / week
What is ‘increasing risk drinking’?
Men: 22-50 units / week
Women 15 - 35 units / week
What is a ‘unit’ of alcohol?
A standard measurement of the alcohol content of a drink. Takes into account the strength (%ABV) and the volume.
Give an equation used to calculate the number of units in a drink.
[ % ABV x volume (mls) ] / 1000 = units
Why do men metabolise alcohol faster?
Due to their %age body fat.
Describe the aetiology of problem drinking.
- Individual
> genes / personality / physique
> occupation
> advertising / availability / peer group - Family
> Religion / tradition / culture
Why are women now drinking more than ever?
- more socially acceptable
- more disposable income
- more drinks marketed at women
- more drinking places aimed at women customers
Give 5 social + psychological risk factors for problem drinking
- Drinking within the family
- Childhood problem behaviour relating to impulse control
- Early use of alcohol, nicotine + drugs
- Poor coping responses to life events
- Depression as a cause (not a result) of problem drinking
How might Alcohol + Deprivation be linked?
Adverse effects of alcohol exacerbated amongst lower SE groups
- more likely to experience negative effects directly and indirectly
- lack of money means they are less likely to protect themselves against negative health + social consequences
- more likely to die of causes influenced by - or attributable to - alcohol
What are the 4 most common causes of death due to alcohol?
- Accidents + violence
- Malignancies
- Cerebrovascular disease
- Coronary Heart Disease
Alcohol causes multi system disease, and has physical, psychological + social implications. What might be some of the physical manifestations of alcohol disease?
- Liver disease
- Birth defects -> fetal alcohol syndrome
- Respiratory
- Neurological
- Haematological
- Rheumatological
Describe the possible progression of liver disease in an alcoholic.
Fatty liver -> Cirrhosis
- No significant risk of liver damage at less than 30g alcohol / day
- Fatty liver reversible on withdrawing alcohol
Give some symptoms of mild - moderate alcoholic hepatitis.
- Anorexia
- Nausea
- Abdominal pain
- Weight loss
- patients are more susceptible to infection
What are the signs of severe alcoholic hepatitis?
- Ascites
- Bleeding
- Encephalopathy
- severe alcoholic hepatitis is a medical emergency
What is the relationship between alcohol + heart disease?
- Moderate alcohol intact can protect against interstitial heart disease
- Heavy alcohol use increases risk -> hyperlipidaemia, hypertension
> alcohol can precipitate arrhythmias eg. Atrial Fibrillation
What is the relationship between alcohol + cancer?
- 25-50% head and neck cancers due to alcohol
- Other alcohol-related cancers: breast, liver, stomach, colon, rectum, pancreatic
What is the recommended alcohol intake during pregnancy?
- None in the 1st trimester
- 2-3 units / week in 2nd + 3rd trimesters
How does excess alcohol intake affect a pregnancy?
- Increased rate of miscarriage
- Low birthweight babies
What does persistent drinking throughout pregnancy lead to?
Foetal Alcohol Syndrome
- small, underweight babies; slack muscle tone
- mental retardation; behavioural + speech problems
- characteristic facial appearance
- cardiac, renal + ocular abnormalities
What percentage of Child Protection cases involve parental alcohol use?
30 - 60%
What can be done to curb alcohol usage?
- Increase price + decrease supply
- Screening + brief interventions from healthcare workers
- Develop a more ‘joined up’ approach from services
What Public Health measures might be used to reduce alcohol usage?
- Minimum price per unit of alcohol
- Change licensing laws in areas where cirrhosis is the biggest problem
- Reduce ‘passive drinking’ effects
What is the recommended management for people requesting help with an alcohol problem.
- Perform physical + mental assessment
- Offer appropriate investigation(s) + follow up
- Offer referral / treatment as appropriate
What should you consider under ‘general support + care’ for a person requesting help with an alcohol problem?
- Address other health issues, as well
- Consider vitamin supplementation
- Assess interstitial heart disease risk
- Consider osteoporosis risk
- Tailor health assessment to an individual
When should blood tests be used with regards to a person who is known to drink alcohol in excess?
- Should NOT be used in screening
- use in established alcohol-related disorder to assess severity + progress in primary care / hospital
What screening questionnaires can be conducted if a person is suspected of excessive alcohol consumption?
Who are these questionnaires recommended for?
- AUDIT or CAGE
- Recommended for ‘at risk’ groups, including children
When should you consider using the AUDIT or CAGE questionnaires?
- Consider in all adults presenting with health problems commonly linked to alcohol problem drinking
- not blood tests
What does the AUDIT questionnaire (alcohol use) comprise?
- 10 point questionnaire; 5 mins to carry out
- Hazardous drinking: Score 8 +
- Alcohol dependence: Women = 13; Men = 15
What are the 4 questions which make up the CAGE questionnaire?
- Have you ever thought you needed to cut down on your drinking?
- Have you ever become angry / annoyed at people criticising your drinking?
- Do you ever feel guilty about your drinking?
- Have you ever had an eye-opener in the morning to ease your hangover?
What is the sensitivity + specificity of the CAGE questionnaire for alcohol usage?
Sensitivity = 87% Specificity = 65%
Brief structured advice (Motivational interviewing) has been shown to reduce alcohol intake. What might this discussion cover?
- Potential harm caused
- Reasons for changing
> health + wellbeing benefits
> obstacles to change
> strategies to combat
> goals
What medications might be used to prevent an alcoholic person from relapsing?
- Disulfiram -> sensitise against alcohol
- Acamprosate -> GABA blocker
- Naltrexone -> used in specialist centres
- none of these agents are particularly effective
How is Alcohol Dependence Syndrome classified?
Cluster of 3 of the below symptoms in a 12 month period:
- Tolerance: increasing the amount of alcohol to achieve the same effect
- Characteristic physiological withdrawal
- Difficulty controlling onset, amount + termination of use
- Neglect of social + other areas of life
- Spending more time obtaining + using alcohol
- Continued use, despite negative physical and psychological effects
What is Wernicke’s Encephalopathy?
- Vitamin B1 deficiency, often occurring on withdrawal of alcohol.
- Reversible.
- Not treating can lead to Korsakoff’s.
Wernicke’s Encephalopathy is characterised by a triad of symptoms. Name these symptoms.
- Acute mental confusion
- Ataxia
- Ophthalmoplegia
How should Wernicke’s Encephalopathy be treated?
- Timely injections of Thiamine (Vitamin B1)
- Poorly absorbed orally
- Small risk of anaphylaxis when given IV.
What is Korsakoff’s syndrome?
- Amnestic disorder due to enduring B1 malnutrition
- not reversible
- short term memory loss
- lose spontaneity, initiative
- confabulation -> disturbance in memory, defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world.
How is diagnosis of Korsakoff’s syndrome made?
CT scan
What is Delirium Tremens?
- A short-lived (3-5 days) toxic confusional state which usually occurs as a result of reduced alcohol intake in alcohol dependent individuals with a long history of use.
What symptoms might a person experiencing delirium tremens present with?
- Clouding of consciousness / confusion / seizures
- Hallucinations in any sensory modality
- Marked tremor
What is the treatment for Delirium Tremens?
- Supportive:
> Fluids
> Benzodiazepines - Detoxification in acute situation -> use Benzodiazepines
- Need support: effective in short term in hospitals
- Don’t forget about Pabrinex!!! (Vitamin B1)
BME communities are at greater risk of developing some of the leading causes of sight loss. Name the top 3.
- Glaucoma
- Cataracts
- Diabetic eye disease
Name the 6 most common eye conditions leading to sight loss.
- Cataracts
- AMD (Age-related macular degeneration)
- Glaucoma
- Retinitis pigments
- Hemianopia
- Retinopathy
Describe the manifestation of cataracts.
- Lens becomes less transparent as we age
- If the lens turns misty / cloudy -> this is a cataract
> cataract can get worse -> makes vision mistier
What is ‘macular disease’?
A collective term for conditions which cause damage to the cells of the macula (the central part of the retina) + affects central vision.
Describe the visual changes which occur in AMD (Age-related Macular Degeneration).
- Peripheral vision is not affected
- AMD causes blurred, distorted or dim vision
- May progress very slowly
Which group of people does AMD (Age-related Macular Degeneration) tend to affect?
Over 65s: AMD is the leading cause of sight loss in the over 65s.
What is the cure for AMD? How can you decrease the risk of developing AMD?
- No cure
- Slow / halt the disease progression with medical treatment, drug therapy or laser treatment.
- Decrease risk by having regular sight tests
What is ‘glaucoma’?
- Group of eye conditions which affect the optic nerve
- damage may be caused by raised eye pressure or a weakness in the optic nerve
Describe the visual changes which occur in glaucoma.
- No symptoms in early stages
- Peripheral vision is affected; damage can’t be reversed
- Leads to blindness without early diagnosis + treatment.
What are the risk factors for glaucoma?
- Increased age
- Family History of glaucoma
What should you offer someone who is over 40 + who has a family history of glaucoma?
- Free eye health checks
- Available to anyone over the age of 40yrs with a family history of glaucoma.
What is ‘retinitis pigmentosa’?
- Inherited conditions of the retina -> lead to a gradual, progressive reduction in vision.
Describe the visual changes which occur with Retinitis Pigmentosa.
- Initially: difficulties with night vision + peripheral vision
- Then: reading, colour + central vision are affected
- Visual deterioration occurs over years, not months.
- Regular sight tests should pick up any changes in vision.
Describe the visual changes which occur with ‘Hemianopia’?
- Sufferers lose either the Left or Right half of the visual field in both eyes following a stroke
What pathology might give rise to a person suffering from hemianopia?
- Stroke
- Traumatic Brain Injuries
How does Diabetic Retinopathy affect the eyes?
- Affects blood vessels supplying the retina
- Blood vessels become weak + damaged -> serious if untreated
What is the leading cause of blindness in the under 65s?
Diabetic Retinopathy
What is the treatment for Diabetic Retinopathy?
- Laser eye treatment
- Laser treatment can’t restore the sight already lost, but could stop the condition progressing further.
What might visually impaired people need to ensure communication is easier for them?
- Large print
- Audio
- Email (voice activated)
- Mobile phones / text
- Braille + Moon
- Speech packages
When might people need SRSB (Sheffield Royal Society for the Blind)?
- From birth
- Hereditary conditions
- Following an accident
- Emotional support
- Degenerative conditions
- Following an illness
- Care in later life
How might people access SRSB services?
Sheffield Royal Society for the Blind
- Self referral
- GP / Optician
- Mobile Information Unit
- Family / friend
- Low vision clinic
- Fire + Rescue service
- Community Engagement Team
Define ‘disability’.
A disability is related to anyone who has a physical, sensory or mental impairment which seriously affects their daily activities.
Not all visually impaired people are visually impaired in the same way. What things might visually impaired people be able to see / not see?
- Nothing
- Differentiate between light + dark
- No peripheral vision
- No central vision
- Patchwork of blanks + defined areas
- Some may see enough to read text, although they may have difficulty crossing roads.
What is Charles Bonnet Syndrome?
- When visual loss occurs, the brain doesn’t receive pictures as previously occurred.
- Sometimes, new fantasy pictures (or old pictures stored in the brain) are released + experienced as though they were seen.
Who does Charles Bonnet Syndrome affect?
- Condition affects people with serious sight loss
- Generally affects those who’ve lost their sight later in life.
- May also affect people who suffer from AMD or retinal disorders.
