PUBLIC HEALTH Flashcards
Causes of child death worldwide
- Pneumonia, acute respiratory infection
2. Diarrhoea (malnutrition is major component)
Prevention measures for diarrhoea
Access to safe drinking water
Sanitation/ access to toilets
Hand hygiene
Most common causes of diarrhoeal illness
1. Viruses (90% in adults; 70% in children) Rotavirus Norovirus Adenovirus Astrovirus
Leading cause of diarrhoea in children worldwide
Rotavirus
What is the difference in rotavirus transmission between developed and developing countries
Developing - all year around transmission
Developed - seasonal transmission
How is the rotavirus vaccine delivered to children and at what are in UK. What effect does the vaccine have on transmission.
Oral vaccine given at 8 and 12 weeks.
70% reduction in transmission.
What are the commonest work related diseases in UK
- Work related stress
- Work related MSK problems
- Work related lung disease
- Work related cancer
- Noise induced hearing loss
- Hand arm vibration
What is the difference between case control and cohort studies
Cohort studies the line of enquiry is always forward, even if its retrospective. You dont have the disease outcome, its looking at exposure to outcome, rather than outcome to exposure (this is case control)
Case control its backwards - in this situation you have your disease state already and you are looking backwards at what the risk factors were
What study design is best suited to
calculating attributable risk?
Attributable risk is mostly calculated in cohort
studies, where individuals are assembled based
on exposure status and followed over a period
of time.
What are the different patterns of occupational disease presentation
Acute Cumulative Progressive (disease progression after exposure ceases) Diseases with latencies.
Define hazard and risk
Hazard = potentially harmful Risk = probability of harm
List some common work hazards
Mechanical Physical Chemical Biological Psychosocial
What factors make work “good for you”
Precariousness – stable, risk of loss, safe
• Individual control – part of decision making
• Work demands – quality and quantity
• Fair employment – earnings and security from employer
• Opportunities – training, promotion, health, “growth”
• Prevents social isolation, discrimination & violence
• Share information, participate in decision making collective bargaining, justice
if conflicts
• Work/life balance
• Reintegrates sick or disabled wherever possible
• Promotes health and wellbeing – psychological needs self efficacy, self
esteem, belonging and meaningfulness
How can you identify an occupational work disorder
An illness that fails to respond to standard treatment, does not fit the typical demographic profile or is of unknown cause should raise suspicion of an occupational etiology
Flags for occupational work disorder
Illness doesnt fit normal demographic - eg. back pain in young person
Doesn’t respond to treatment
Unknown cause
Gets better away from work/ holidays
List some good screening questions for occupational work disorders
- What type of work do you do?
- Do you think your health problems might be related to your work?
- Are your symptoms different at work and at home?
- Are you currently exposed to chemicals, dusts, metals, radiation, noise or repetitive work? Have you been exposed to chemicals, dusts, metals, radiation, noise or repetitive work in the past?
- Are any of your co-workers experiencing similar symptoms?
If the answers to one or more of these questions suggest that a patient’s symptoms are job related or that the patient has been exposed to hazardous material, a comprehensive occupational history should be obtained.
Outline an occupational health history
-Current job, employer, duration • Tasks as well as job title • Past employers and jobs • A brief exposure can be enough • External and internal exposure • Hobbies? (DIY, pets, gardening, chemicals) • If you’re suspicious don’t give up !
What are the risks of being out of work on health
Greater risk than many “killer diseases” • Greater risk than most dangerous jobs (e.g. construction, fishing, etc) • 2 to 3 times risk of mental illness • 2 to 3 times risk of poor health • Loss of fitness and well-being • Social exclusion and poverty • Trapped on benefits to retirement
Define disability as per the Equality act 2010
A physical or mental impairment, which has a
substantial long-term adverse effect on a
person’s ability to carry out normal activities
Type of impairment is broadly defined
Substantial adverse effect
Long-term
Normal activities
What should employers do for those with disability, as per the Equality 2010 act
• altering the person’s working hours
• allowing absences during working hours for medical
treatment
• giving additional training
• getting special equipment or modifying existing equipment
• changing instructions or reference manuals
• changing an open plan working policy to accommodate
someone with an anxiety condition or autism
• providing additional supervision or support
• making adjustments to premises
What public health (population based) approaches can be used to help prevent occupational diseases
Levels of prevention
‒ Primary (e.g. monitor risk, controlling hazards, promotion)
‒ Secondary (e.g. screening, early detection, task modification)
‒ Tertiary (e.g. rehabilitation, support)
• Musculoskeletal - https://www.sheffieldachesandpains.com/
• Mental health - https://www.england.nhs.uk/mentalhealth/adults/iapt/
• Occupational asthma - http://www.hse.gov.uk/asthma/
What is length time bias
This is when a random interval is selected for analysis, that favours slow growing tumours for inclusion in analysis. This is because slow growing tumours have a longer asymptomatic period so these pts will be eligible for screening, where as those with fast growing will be symptomatic faster and not included. This distorts survival time from screening.
SELECTION BIAS
What is lead time bias
This is when disease survival looks better after screening but the actual length of the disease is unchanged, survival time is only increased because the disease what identified at an earlier time point, survival is the same.
What are the risks & benefits of PSA screening
Benefits
Early diagnosis of localised disease (cure)
Early treatment of advanced disease (effective palliation)
Risk
Overdiagnosis of insignificant disease
Harm caused by investigation/ treatment
What are the risks of opportunistic screening for prostate cancer
Conflicting opinion – increased anxiety Poor QA of procedures Iniquitous access Variable intervals of testing Costs ?
What is the prognosis for prostate cancer
Depends on what grade and stage you have
Localised prostate cancer - natural disease course unknown
Loalised advanced
Advanced metastatic = 2.5 years
Overall, around 8 years survival.
Only approx 1/4 die of prostate cancer, most men with prostate cancer die of another illness
Describe a typical patient with prostate cancer
Male, over 50
Presenting with symptoms - probably in 70s
Presenting without symptoms - 50-60s
How does prostate cancer metastasise
Through capsule - Lymph nodes - Bone
What is the grading system used for prostate cancer
Gleasons
1-5
What is the staging system used for prostate cancer
TNM
T = can stage by DRE
T1 - non palpable mass
T2 - palpable mass - localised to prostate
T3 - palpable mass - extended beyond prostate
N = can stage by MRI/ CT to look at noded M = can stage by bone scan to look at mets
HIV transmission routes
Blood, Vertical, Sex
What is the infective rate of HIV
Really low!
0.04 - 3% - highest with anal sex
Compare to syphilis, 40-60% - actually quite low
What is the May & Anderson 1987 model, what is it used for
It is a model that is used to describe STI transmission R = BCD R = reproductive rate B = infective rate C = no of partners D = Duration of infection
What is the diagnostic criteria for substance dependence as per ICD-10
3/6 of the following within the past 12 months
- Tolerance
- Drug withdrawal
- Compulsion or increased desire to take drugs
- Loss of control over drug use, (onset, level, termination, i.e. increasing binges etc)
- Prioritising drug seeking or taking over other interests
- Continued drug use and seeking despite negative consequences (personal, professional, social etc)
Outline theories on the causes of addiction/ approaches to intervention
1.Disease model - intervention is based around substitute drugs to stabilise physiology before terminating drug use. Vaccinations for high risk groups.
2.Behavioural model - interventions based around deincentivising drugs, eg punishments for drug use
3.Volitional model - interventions based around improving behavioural control
4.Socio-cultural - Target poverty, social exclusion, housing and mental health
problems etc
What are the impacts of substance misuse
Acute
Individual harms - medical - overdose, adverse drug reaction
Aggression/ violence - social
A&E attendance - costs
Chronic Dependence Family breakdown Relationship and peer breakdown Unemployment Isolation and mental health problems Behavioural problems Many illnesses - pancreatitis, liver disease, CNS disease, peripheral neuropathy etc Crime and violence More costs to NHS
What are the risk factors for dependence
Family - disorganised, chaotic, FHx of drug use, conflict, poor parenting, domestic abuse, being in care
School/ community - poor attainment in school, low social mobility in community, disorganised community, availability in community, community norms
Individual & peer group - peer recognition, risk taking/ sensation seeking, positive attitude towards antisocial behaviour, rebelliousness, alienation, experience of trauma
What are protective factors against addiction
Cohesive family and community, academic achievement, opportunities, recognition, reward for positive involvement, opportunities to develop self-confidence, worth, resilience
What is the difference between physical and psychological dependence
Physical dependence is associated with the development of tolerance (increased use for same effect) and withdrawal when terminating drug use. The mechanisms are physiological and manipulation of homeostatic systems.
Psychological dependence is feeling that you cannot liver or that life is impossible without a drug. The mechanism is changes in mood and behaviour in response to drug use.
What is included in the 2017 National Drug Strategy
-Reducing Demand • Restricting Supply • Building Recovery in Communities • PHE supports local councils to procure provision specific to local need – funding has decreased significantly in recent years since no longer ring-fenced • Family/community involvement • Payment by Results • Abstinence focussed with greater emphasis on recovery and peer support
What determines the appropriate treatment of drug dependence
The drug(s) they are using
The levels and pattern of their drug use (e.g. are they dependent?)
Their choices and preferences for support
What they have tried before (if anything)
Their mental and physical health
Other issues, e.g. housing, employment
Give some examples of different patient groups who may suffer from drug dependence
- Young people
- People with mental health problems
- Older people
- LGBT people
- Vulnerable groups, e.g. homeless people, sex workers
What local provision (GP) is there for drug dependence
Harm reduction services e.g. needle exchange, advice re reducing risks of use Open access service Structured psychosocial interventions Prescribing services Detox (community or inpatient) Access to residential rehab Recovery support / mutual aid
Give an example of a psychosocial intervention for substance dependence
Motivational intervention (structured counselling) Provide support (in the form of structured counselling) for those who do not feel able to stop drug use Support offered during substitute therapy or detox Support and planning strategies for relapse prevention and prolonged abstinence
What treatment options are there available for substance dependence
Psychosocial interventions - eg motivational/ supportive Prescribing regimes - substitute and maintenance therapy Inpatient or outpatient detox regimes Residential rehabilitation (3-12 months)
What is one alcohol unit
10mls of pure alcohol (or 8g)
Calculate units by:
Strength (%) x volume / 1000
What are the recommended guideline for alcohol consumption
No more than 14 units per week, across 3 or more days
This is the same for men and women
It is the equivalent of no more than 6 beers or 6 glasses of wine a week
What does the recommended guideline represent in terms of harm
When you start drinking above this you are at risk of more alcohol related harm, eg liver disease, cancers etc
What is the alcohol harm paradox
What can explain this paradox
Lower SE groups consume less alcohol than higher SE groups but experience more alcohol related harms than high SE groups
Extreme drinking - low SE groups may consume less overall but when they drink they have more extreme (/dangerous) drinking patterns (eg binge)
List some of the main complications of harmful drinking
Hypertension Coronary heart disease Stroke Liver - AFLD, Liver fibrosis and Cirrhosis - leading cause of liver deaths in UK Pancreatitis
List some of the acute consequence of harmful drinking
Accidents and injury • Coma and death from respiratory depression • Aspiration pneumonia • Oesophagitis/ gastritis • Mallory-Weiss syndrome (gastric tears) • Pancreatitis • Cardiac arrhythmias • Cerebrovascular accidents • Neurapraxia due to compression • Myopathy/rhabdomyolysis • Hypoglycaemia
List some of the chronic medical effects of alcohol excess
• Pancreatitis • CNS toxicity: – dementia – Wernicke-Korsakoff syndrome – cerebellar degeneration – Marchiafava-Bignami syndrome – central pontine myelinolysis • Liver damage: – fatty change – hepatitis – Cirrhosis – Hepatic carcinoma
What is the commonest cause of alcohol related death
Alcohol related liver disease
What hospital services are most affected by alcohol
Cardiovascular
Mental health and behavioural services
Liver disease
List some of the features of FAS/D
-Pre and post-natal growth retardation
• CNS abnormalities including mental retardation,
irritability, incoordination, hyperactivity
• Craniofacial abnormalities
• Associated abnormalities including congenital defects of
eyes, ears, mouth, cardiovascular system, genitourinary
tract and skeleton and an increase in the incidence of
birthmarks and hernias
List some of the possible symptoms of alcohol withdrawal
Tremours Tonic-colonic seizure Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure Hallucinations - usually visual
List some of the psychosocial effects of excessive alcohol consumption
• Interpersonal Relationships – Violence – Rape – Depression or anxiety • Problems at Work • Criminality • Social Disintegration – Poverty • Driving incidents/offences
List some examples of primary prevention for excessive alcohol use
THINK! campaign to reduce drink driving
Drinkaware apps to track drinking/ units consumed per week, and labelling on bottles
Restrictions on advertising to young people and sex associations
Minimum unit pricing
What effects would minimum unit pricing have on alcohol related harm
Reduce alcohol related deaths
Alcohol related hospital admissions
Reduce alcohol related crime
Financial savings to NHS
How would you screen for alcohol dependence
Clinical interview Tools: FAST - for harmful alcohol use AUDIT - for dependence CAGE - 2 or more = alcohol problem
List some questions that you could ask as part of alcohol screening in a clinical interview
- Ask about days of heavy drinking - week or month
- Ask about the following:
Failure to do role bc of drinking
Law - run ins bc of alcohol
Trouble - relationships bc of alcohol
Harms - bodily harms bc of alcohol
If yes to any of above - likely alcohol abuse –> do assessment for alcohol dependence - 3 or more of any of the ICD-10 criteria
Tolerance
Withdrawal
Not able to drink within limits - drink more than you wanted to/ expect
Drink instead of doing other hobbies/ interests
Drink despite negative consequences - loss of job, relationship breakdown etc
Drink instead of doing whats expected of them - job, family etc
Give an example of an intervention for alcohol dependency
FRAMES - MOTIVATIONAL INTERVIEWING
-Feedback about the risk of personal harm or impairment
• Stress personal Responsibility for making change
• Advice to cut down or, if necessary, stop drinking
• Provide a Menu of alternative strategies for changing drinking
patterns
• Empathetic interviewing style
• Self efficacy: intuitive style which leaves patient enhanced in
feeling able to cope with goals they have agreed
List some contraindictations for prescribing benzos for alcohol WD
Hypersensitivity to benzodiazepines Severe pulmonary insufficiency Phobic & obsessional states Chronic psychosis Severe hepatic insufficiency (may precipitate encephalopathy Pregnancy Myasthenia gravis
List some of the WD effects of benzos
Can occur when treatment stops abruptly (if physically dependent). Headache Muscular pain Anxiety Hallucinations Epileptic seizures
Why should benzos never be prescribed for more than 4 weeks and why do they need tapering regime
Risk of dependency increased when prescribed for longer than 4 weeks
Taper bc if you dont step down the dose the pt will have a WD reaction to the benzo
List some of the drug interactions of benzos
Alcohol: Enhanced sedative effect.
Centrally acting drugs. Antipsychotics, analgesics & sedative anti- histamines. Enhanced central depressive effects.
Anti – epileptic drugs. Side effects & toxicity more evident when used concurrently.
Compounds affecting hepatic enzymes (cytochrome P450). Reduced clearance rate EG Disulfiram.
Who should be prescribed benzos at reduced dose
Elderly
Respiratory impairment
Organic brain damage
No more than half usual adult dose.
What AST/ALT ratio differentiates AFLD and NAFLD
Alcoholic liver disease:
AST:ALT >2 - raised AST to ALT
Non alcoholic:
AST:ALT <1
Describe the LFT result of alcohol fatty liver disease
AST 8x elevated
ALT 5x elevated
AST:ALT ration >2
I think this means AST is more specific for alcohol pathology
Aspartate transaminase
Alanine transaminase
How would you treat wernickes encephalopathy in alcoholics
VitB/ Thiamine
List the treatment for alcohol withdrawal
Chlordiazepoxide
If have hepatic problem - lorazapam as does not interact with CP450 enzymes
List the treatment for relapse prevention
Acamprosate - GABA a modulator - decreases cravings & stress
Disulfiram - disrupts metabolism of alcohol, makes pt sick bc of build up of acetaldehyde - NB - nasty side effects, SOB, tachy, nausea etc
Nalmefine - opioid antagonist, reduce reward/ pleasure, can be PRN - useful for patients who have problems with binge drinking
What is the healthy child programme
Nationwide prevention programme for pre-school school children. The programme aims to improve child health and well-being through identifying and preventing causes that start in early life.
Roles within the health child programme
Midwives - manage most of the antenatal things - blood tests (screening of mum), measurements, urine tests (protein) etc. Do heel prick test after baby is born for CF etc.
Health visitor - manage most of the postnatal stuff. Get 5 visits before 5.
7 month pregnant
2 weeks post birth
2 months
9-12 months
2 - 2.5 years
Role - parenting skills, eg sleep routine etc; development needs of baby - feeding ok etc, check home and family life - mum/ dad ok etc - think of this as more ‘health & wellbeing’
GP - not much preterm unless needed. 2 month baby check - eyes, heart, hips, testes for boys
What is the red book?
Health record held by parents - purpose it to record all health/ development info about the baby. Eg. to record weight, height, development milestones, vaccinations
What is recorded in the red book?
Baby height, weight, development milestones and vaccinations
What is recorded in a babies growth chart
weight, head circumference, length,
How often are babies weighed
first 2 weeks
1-6 months: every month
6-12: every other month
1+ : every 3 months
When should a change in a baby’s weight be considered significant
If it tracts out of 1 centile consistently
They can drop off but have to come back within the centile by the next weigh in
sustained drop through two or more weight centile spaces is unusual (fewer than 2% of infants) and should be carefully assessed by the primary care team, including measuring length/height
What is included in the 8 week baby check/ post natal check
Baby physical examination - eyes, heart, hips, testes
Outline the child vaccination schedule
2 months: 6 in 1. DTP+Pertussis Pneumococcal vaccine Rotavirus Men B
3 months:
6 in 1
+ Rota
4 months:
6 in 1
+PCV
+Men B
1 year: MMR 4 in 1 Men b Men c PCV
2-7 nasal flu
What test would you do to look for thoracic outlet syndrom
Adson’s
Test for subacromial impingement
Hawkins Kennedy
Test for acormial-clavicle (AC) joint impingement
Scarf test
What is included in the Bradford Hill criteria
Strength of association (effect size)
Consistency (reproducible)
Temporal (disease occurs after risk factor/ variable)
Biological effect (increase in cause = increase outcome)
Specific - must be specific association between risk factor and disease
Coherence - between epidemiology and lab results
Analogy
Give some examples of primary prevention strategies to improve MSK problems
Exercise guidelines - 150 minutes of moderate aerobic exercise per week, walking, cycling etc
x2 days of weight based exercises for all muscle groups
Diet and weight management - change for life
Transport - more cycle lanes and pedestrian pathways so that people are encouraged to exercise
Work exercise incentives - cycle to work scheme etc
Give an example of occupational health inequality
People from low SE backgrounds have jobs with the most physically demanding jobs with highest levels/ risk of occupational disease.
Give an example of a population approach to improve mental health
IAPTs - improving access to psychological therapies
Primary and secondary
Time to change campaign
Give an example of a population based approach to occupational asthma
Campaigns that promote wearing masks at work to prevent asthma
What percentage of COPD is work related
15%
List some causes of occupational COPD
Coal dust, Silica, Cotton, Grain, Cadmium, isocyanates, generic VGDF
Foundry work, joiners, construction workers, welders
What percentage of cancers are occupational
13%
What studies are used in epidemiology
Ecological Case control Cohort Cross section Interventional
