Public Health Flashcards
1
Q
Give the 4 domains of public health.
A
- Health protection.
- Improving services.
- Health improvement.
- The wider determinants of health - looking at the bigger picture.
2
Q
Name 5 ethical theories.
A
- Virtue.
- Categorical.
- Imperative.
- Utilitarianism.
- 4 principles.
3
Q
Sociology of health medicine: name 5 determinants of illness.
A
- Social class.
- Unemployment.
- Racism/discrimination.
- Material deprivation/poverty.
- Gender.
4
Q
Describe the Health Belief Model (Becker 1974) of behavioural change.
A
The individual needs to believe that there are consequences and that they are susceptible to disease. They need to believe that taking action reduces the risks and that the benefits outweigh any costs.
5
Q
Describe the Transtheoretical model of behavioural change.
A
- Pre-contemplation (no intention of giving up smoking).
- Contemplation (consider quitting).
- Preparation (get ready to quit in near future).
- Action (engaged in giving up).
- Maintenance (steady non-smoker).
- Relapse?
6
Q
What is the Gini coefficient?
A
A statistical representation of a nation’s income distributed among it’s residents. It is the most commonly used measure of equality.
7
Q
Responses to health inequalities: what are the main principles of the Acheson Report (1998)?
A
- Reduce income inequality.
2. Give high priority to the health of families with children.
8
Q
Responses to health inequalities: what are the main principles of Proportionate Universalism?
A
- Focusing only on the disadvantaged will not reduce inequalities.
- Action needs to be universal.
- A fair distribution of wealth is needed.
9
Q
What are the main principles of Virtue ethics?
A
- Focuses on the person who is acting; are they expressing good character?
- Integrates reason and emotion.
- Virtues are acquired.
- An action is virtuous only if the person is acting with the genuine intention of doing the right thing.
10
Q
What are the challenges/criticisms of Virtue ethics?
A
- Virtues are culture-specific.
- Too broad for practical application.
- Kindness and compassion could lead to not telling the harmful truth - lying.
- It is not always clear how to resolve a dilemma with virtue ethics.
11
Q
What are the 4 principles of ethics?
A
- Autonomy (respect the patient’s decision).
- Benevolence (provide benefits to the patient).
- Non-maleficence (do no harm).
- Justice (ensure fairness in the distribution of treatment).
12
Q
What does the GMC say are the 5 main ‘duties of a doctor’?
A
- Protect and promote health.
- Provide a good standard of care.
- Recognise and work within the limits of your competence.
- Work with colleagues in a way to best serve your patients.
- Treat patients as individuals and respect their dignity.
13
Q
Name 4 ways to assess functional limitations among older people?
A
- The Katz ADL scale.
- IADL.
- The Barthel ADL index.
- MMSE.
14
Q
What activities of daily life does the ‘Katz ADL Scale’ include?
A
Bathing, dressing, toilet use, eating, urine and bowel continence, transferring in/out of bed.
15
Q
What activities of daily life does the ‘IADL Scale’ include?
A
Use of the telephone, travelling by car or public transport, food/clothes shopping, cooking, housework, medication use, money management.
16
Q
What activities of daily life does the ‘Barthel ADL index’ include?
A
Feeding, grooming, bathing, dressing, walking on a level surface, going up and down stairs, moving from wheelchair to bed, continence, transferring to and from a toilet.
17
Q
What does the MMSE test?
A
- Orientation, immediate memory.
- Short-term memory.
- Language functioning.
18
Q
List 5 challenges of an ageing population.
A
- Strains on pension and social security systems.
- Increasing demand for health care.
- Bigger need for trained health professionals.
- Increasing demand for long term care.
- Pervasive ageism (denying older people rights and opportunities).
19
Q
What can cause an ageing population?
A
- Improvements in sanitation, housing, nutrition and medical interventions.
- Rising life expectancy.
- Falls in fertility - people are having fewer children and having them later.
- Decline in premature mortality.
20
Q
What is intrinsic ageing?
A
A natural, universal, inevitable process.
21
Q
What is extrinsic ageing?
A
Ageing dependent on external factors e.g. UV exposure, smoking etc.
22
Q
What physical changes happen to the body later in life?
A
- Loss of skin elasticity and hair colour.
- Decrease in size and weight.
- Loss of joint flexibility.
- Increased risk of illness.
- Decline in learning ability and less efficient memory.
23
Q
Why do women generally live longer than men?
A
- 20% biological - premenopausal women are protected from heart disease by hormones.
- 80% environmental - men take more lifestyle risks than women.
24
Q
Give 3 consequences of people living longer.
A
- Pensions will have higher pay outs than currently planned.
- Chronic and comorbid conditions will prevail.
- Rising inequalities as more affluent groups will use health services for longer.
25
List 4 types of dementia.
1. Alzheimer's disease (62%)
2. Vascular dementia (17%)
3. Mixed alzheimer's and vascular (10%)
4. Lewy bodies (6%)
26
What is medicalisation of death?
Death is seen as a failure. There is a curative endeavour to prolong life at any cost. Death as a natural part of life is challenged.
27
What is meant by institutionalising death?
60% of people die in hospital but 70% want to die at home.
28
Glaser and Strauss (1965): What 4 awareness contexts did they identify?
1. Closed awareness.
2. Suspicion awareness.
3. Mutual pretence.
4. Open awareness.
29
What is closed awareness?
When the patient is unaware of their own impending death but others (staff and family) are aware.
30
What is suspicion awareness?
The patient suspects that they are dying and tries to seek confirmation of this.
31
What is mutual pretence?
Everyone knows the patient will die, including the patient, but it is not discussed.
32
What is open awareness?
Everyone knows the patient is likely to die and talks openly about it.
33
Describe 'death the hospice way'.
- Open awareness, compassion, honesty.
- Emotion and relationships.
- Holistic care.
- Multi-disciplinary teams.
34
Describe the chain of infection.
1. Susceptible host.
2. Causative micro-organism.
3. Reservoir (patients, visitors etc).
4. Portal of entry/exit.
5. Transmission.
35
How can an infection be transmitted?
1. Exogenous spread - direct contact (STI's), airborne (TB), vector spread (malaria).
2. Endogenous spread - self spread.
36
Give three types of handwashing.
1. Routine handwash.
2. Hygienic hand antisepsis.
3. Surgical handscrub.
37
Describe the physiological effects of nicotine?
- Activation of nicotinic Ach receptors in the brain. This causes dopamine release.
- Dopamine is a stimulant. Tolerance increases and cessation will result in withdrawal.
38
List some health problems connected to smoking.
Cardiovascular problems (stroke, MI), cancers, COPD, stomach ulcers, diabetes, oral health problems etc.
39
What methods can be used in smoking cessation?
1. Nicotine replacement therapy - patches, gums, nasal spray etc.
2. Non-nicotine pharmacotherapy - Varenicline, Bupropion.
3. Transtheoretical model.
40
What are the 3A's?
1. Ask - ask the patient about smoking.
2. Advice - advice on smoking cessation methods.
3. Assist - refer to local NHS stop smoking services.
41
What are the 8 millenium development goals?
1. Eradicate poverty and hunger.
2. Universal primary education.
3. Promote gender equality.
4. Reduce child mortality.
5. Improve maternal health.
6. Combat HIV, malaria and other diseases.
7. Ensure environmental sustainability.
8. Develop a global partnership for development.
42
What are the three leading causes of death in children in the developing world?
1. Diarrhoea.
2. Pneumonia.
3. Malaria.
43
What is the significance of Lampedusa?
Lampedusa is an Italian island that is a primary transit point for immigrants from Africa. It is the closest EU territory to the shores of Libya. It is a deadly migrant route.
44
What are the 4 main NHS goals in regards to migrant health?
1. Equality of access.
2. Reducing the gap in health inequalities.
3. To provide services for the vulnerable.
4. Ensuring services are appropriate and accessible.
45
Define sustainability.
Meeting the needs of today without compromising the ability of future generations to meet the needs of tomorrow.
46
What are possible consequences of climate change?
Heatwaves, sea levels rise, new diseases, scarcity of resources resulting in migration/war.
47
What is the Bradford Hill criteria?
A group of minimal conditions necessary to provide adequate evidence of a causal relationship.
48
What could be done help to slow down the effects of climate change?
- Control world population.
- Reduce energy consumption.
- Invest in renewable energy resources.
49
Define screening. What is the main purpose of screening?
A process of identifying seemingly healthy individuals who may be at increased risk of a disease.
Prevention!
50
Define primary prevention.
Preventing a disease/condition from occurring in the first place. Eliminate exposures/risk factors that contribute to the disease.
51
Define secondary prevention.
Detecting a disease as soon as possible in order to alter its course and to improve health outcomes.
52
Define tertiary prevention.
Trying to slow down the progression of a disease and helping people to manage their illness effectively.
53
Define sensitivity.
The proportion of people with the disease who are correctly identified (a/a+c).
54
Define specificity.
The proportion of people without the disease who are correctly excluded by the screening test (d/b+d). How well a test detects those without a disease.
55
Define positive predictive value (PPV).
The proportion of people with a positive test result who actually have the disease (a/a+b).
56
Define negative predictive value (NPV).
The proportion of people with a negative test result who do not have the disease (d/c+d).
57
Define prevalence.
The proportion of a population found to have the disease at a point in time.
58
Define incidence.
The rate at which new cases occur in a population in a certain time period.
59
What is the Wilson and Jungner criteria used for?
To determine whether a condition should be screened for.
60
What are the 10 Wilson and Jungner criteria for screening?
1. The condition should be a serious health problem.
2. The natural history of the condition should be understood.
3. There should be a detectable early stage.
4. There should be a treatment available.
5. Facilities for diagnosis and treatment need to be available.
6. There should be a suitable test.
7. The test should be acceptable to the population.
8. There should be an agreed policy on whom to treat.
9. The cost should be balanced against the benefits.
10. It should be a continuous process, not just a one off.
61
Describe selection bias in regards to screening.
The people who choose to participate in screening programmes may be different from those who don't; proper randomisation is not achieved.
62
Define length-time bias.
Diseases with a longer period of presentation are more likely to be detected by screening than ones with a shorter time of presentation.
63
Define lead-time bias.
Screening identifies diseases earlier and therefore gives the impression that survival is prolonged but survival time is actually unchanged.
64
Define error.
Any preventable event that can cause or lead to patient harm.
65
What are the 3 types of human error?
1. Errors of omission- When required action is delayed or not taken.
2. Errors of commission- When the wrong action is taken.
3. Errors of negligence- When actions or omissions do not meet the standard of an ordinary, skilled person professing.
66
What are the 2 outcomes that medical error can lead to?
1. Adverse event.
| 2. Near miss.
67
Define adverse event.
An incident that results in harm to the patient.
68
Define near miss.
An event which has the potential to cause harm but doesn't develop further, thereby avoiding any harm.
69
What are violations? Name the 3 types of violation.
Deliberate deviations from practices, procedures and standards or rules.
1. Routine - cutting corners.
2. Necessary - to get the job done; unavoidable.
3. Optimising - personal gain, selfish.
70
Describe skill based errors.
When performing a routine, well learnt task you may give little attention. If distracted or interrupted this can result in slips of action or memory lapses.
71
Describe rule/knowledge based errors.
- When an incorrect plan or course of action is taken. This can happen in an emergency situation or can be due to a lack of experience.
- Mistakes are more likely when tasks are complex. This can be due to inexperience, insufficient information, little support/advice from colleagues etc.
72
Name 5 factors that can affect performance.
1. Fatigue.
2. Illness.
3. Drugs or alcohol.
4. Stress.
5. Distraction.
73
What are the two main approaches to managing errors?
1. Person approach (individual). Errors are the product of wayward mental processes e.g. inattention, distraction, negligence. It focuses on the unsafe acts of people on the front-line (nurses, doctors).
2. System approach (organisation). Adverse events are the product of many causal factors, the whole system is to blame (swiss cheese theory).
74
Briefly describe the Swiss cheese theory of errors.
The idea that the interaction between active failures and latent conditions leads to accidents. There are successive layers of defences and safeguards but the 'holes' can still line up and people can slip through the system.
75
Name 5 information processing limitations.
1. Automaticity.
2. Cognitive bias.
3. Cognitive interference.
4. Selective attention.
5. Transferring expectations.
76
What is positive transfer of expectations?
When someone applies a previous experience to a new, similar situation.
77
What is negative transfer of expectations?
When a previous experience conflicts with the current situation.
78
Name 5 qualities of an effective team.
1. Optimal size.
2. A common purpose/goal.
3. Good dynamic.
4. An identified leader.
5. Shared knowledge and experiences.
79
What are the benefits of working in an effective team?
- Improved service delivery.
- Improved decision making.
- Reduces error.
80
Describe 4 obstacles of working in a team.
1. Organisation - different offices/shifts/rotation posts.
2. Location - ward based/home visits/based elsewhere.
3. Management - different employers/sub-teams.
4. Team members may have other commitments - hard to contact people.
81
Give 3 examples of NHS systems that promote teamwork.
1. Shared case notes.
2. Multi-disciplinary team meetings.
3. Team offices.
82
Give 2 examples of checklists used in the NHS.
```
1. SBAR checklist - for reporting a case.
S - situation.
B - background.
A - assessment.
R - recommendation.
```
2. Surgical safety checklist.
83
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.
84
What is the WHO definition of mental health.
Mental health is a state of well-being in which the individual realises his or her own
abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community.
85
Give some examples of common mental health problems (CMHP's).
Depression, anxiety, phobias, social anxiety disorder, OCD, post-traumatic stress disorder (PTSD).
86
Approximately how many people worldwide have depression at any one time?
350 million.
87
Approximately how many people worldwide have a severe mental illness e.g. schizophrenia?
24 million.
88
What are the dangers/consequences of common mental health problems (CMHP's)?
- They have a negative impact on quality of life; effecting employment, ADL's, family.
- They increase the risk of physical illness and they increase the risk of mortality from physical illness.
- Depression is a major risk factor for suicide.
89
What is depression?
Sustained feelings of sadness that interfere with ones ability to function at school, work and at home.
90
What symptoms are characteristic of depression?
Loss of interest, decreased energy, feelings of guilt/little self worth, disturbed sleep, appetite loss.
91
What wider determinants of health may increase your risk of developing a CMHP?
- Unemployment.
- Debt.
- Lack of qualifications.
- Isolation.
- Material disadvantage.
- Living in local authority housing.
92
What is the relationship between socio-economic background and CMHP's?
A wealthy person with a higher occupational status is less likely to develop of CMHP.
93
Why do CMHP's have a major impact on society even though they are less disabling than severe mental health disorders?
The prevalence of CMHP's is large. This results in a huge cumulative cost to society.
94
Name 4 interventions that can help treat CMHP's.
1. Community level interventions- Focuses on strengthening protective factors e.g. school based programmes, activities for the elderly etc. Also tries to reduce risk factors e.g. social support after threatening events.
2. Individual level interventions- The patient could take medications to help e.g. anti-depressants. They could also start attending psychological therapies: CBT, counselling etc. as this follows NICE guidelines for depression/anxiety.
3. Service organisation level- Management within primary care; focusing on prevention and early identification. Holistic. Encouraging self-management.
4. IAPT service model-
- Improving access to psychological therapies.
- The idea is to train more NHS staff in delivering evidence based CBT.
- Provide support for people with CMHP's, help them get back to work and off benefits.
- Psychological services can be paid for by savings made to the benefit bill.
95
What is the psychological definition of stress?
Stress occurs when the demands made upon an individual are greater than their ability to cope.
96
What are the two types of stress?
1. Eustress. Eustress is a positive stress; it is often beneficial and motivating.
2. Distress. Distress is a negative stress; it can be damaging and harmful.
97
Name 4 acute stressors.
1. Noise.
2. Danger.
3. Injuries.
4. Hunger.
98
Name 5 chronic stressors.
1. Work.
2. Family.
3. Friends.
4. Health.
5. Finances.
99
What are the 5 signs of stress.
1. Biochemical.
2. Physiological.
3. Behavioural.
4. Cognitive.
5. Emotional.
100
Name 3 external stressors.
1. Environment.
2. Work.
3. Social and cultural pressures.
101
Give examples of physical and psychological internal stressors.
- Physical: inflammation, infection.
| - Psychological: attitudes, beliefs, personal expectations, worries.
102
Responses to stress: what is the fight of flight model?
An automatic response to external acute stressors. The response elicits physiological changes: hypothalamus, adrenal medulla and cortex are stimulated. Activation and inhibition of organs.
103
Responses to stress: what are the body's responses in the fight of flight model?
- Lungs: take in more O2, rapid breathing.
- Blood flow: increases.
- Skeletal muscles: tense.
- Spleen: more RBC's discharged.
- Skin: blood flow directed away to support skeletal muscles and heart.
- Mouth: drier as saliva dries up.
104
What is the general adaptation syndrome? What are the three stages of general adaptation syndrome (GAS)?
A concept used to describe the body's short term and long term reactions to stress. There are 3 stages.
1. Alarm- A threat/stressor is identified. There is a sudden burst of energy.
2. Adaptation/resistance- The body attempts to adapt or resist the stressor. Defensive countermeasures are engaged.
3. Exhaustion- Energy is depleted; the body begins to run out of defences.
105
What are the 5 signs of stress?
1. Biochemical- Endorphin (peptides that activate opiate receptors) and cortisol (released in response to stress, elevated levels affect learning and memory) levels are altered.
2. Physiological- Shallowing breathing, raised BP, more HCl produced
3. Behavioural- Over-eating, anorexia, insomnia, more alcohol or smoking or drug use.
4. Cognitive- Negative thoughts, no concentration, worse memory, tension headaches.
5. Emotional- Mood swings, irritability, aggression, boredom, apathy (lack of interest), tearfulness.
106
Define the stress-illness model.
An individuals susceptibility to disease or illness is increased because the individual is exposed to stressors which cause strain upon them, leading to psychological and physiological changes.
107
What is the diagnostic criteria for PTSD?
1. The person experienced an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or horror.
108
Give 3 symptoms of PTSD.
1. Recurrent and distressing recollections of the event(s) e.g. in dreams.
2. Persistent avoidance of stimuli associated with the event.
3. Persistent symptoms of increased arousal (when the brain remains 'on-edge', wary and watchful of further threats) e.g. insomnia, irritability etc.
109
Give some examples of traumatic events that may result in PTSD.
1. Childhood physical/emotional/sexual abuse.
2. Violent attacks/war.
3. Natural disaster.
4. Rape.
110
What physical illnesses can be related to stress?
Cancer, CHD, chronic fatigue, infertility/miscarriage, peptic ulcers, IBS.
111
Name 4 stress management techniques.
1. Meditation.
2. Yoga.
3. Exercise.
4. CBT.
112
Medicine in the media: what are the key purposes of NHS press releases?
1. Reactive - defending the NHS' reputation e.g. reporting achievements, improvements, justifications.
2. Pro-active - improving and protecting population health via social marketing messages (five-a-day, change for life etc) and early recognition and symptom awareness campaigns (act FAST).
113
List some diseases that are linked to obesity.
Type 2 diabetes, hypertension, infertility, CHD and stroke, osteoarthritis, cancer (among non-smokers), angina, high blood cholesterol.
114
What has happened to the epidemiological pattern of obesity?
In the past obesity affected the rich, nowadays obesity is a condition associated with poverty and lower socio-economic groups.
115
What are the 3 main components of the aetiology of obesity?
- Biology.
- Environment.
- Behaviour.
116
What is the WHO definition of obesity?
Abnormal or excessive fat accumulation resulting from a chronic imbalance between energy intake and energy expenditure that presents a risk to health.
117
Give 6 causes of obesity.
1. 'Americanisation' of diet and society.
2. Increased car culture, less walking.
3. More commuting.
4. Longer working hours.
5. Greater availability of energy dense food, cheaper and better promoted.
6. Replacing water with sugary drinks.
118
What diagnostic tools can be used in obesity?
- Waist circumference.
- WHR (waist to hip ratio).
- Skinfold thickness.
- BMI.
- MRI.
119
How is BMI calculated?
Weight (KG) / Height^2 (m)
120
What is the range for a normal BMI?
18.5 - 24.9
121
Describe Prader Willi Syndrome.
- Paternal chromosome 15 deletion.
| - The individual will have learning difficulties, growth abnormalities and obsessive eating.
122
What genetic conditions can be linked to obesity?
1. Prader Willi Syndrome.
2. Mutations of the leptin and melanocortin receptors.
3. Congenital leptin deficiency. (leptin: appetite inhibitor).
123
What aspects of behaviour can be associated with weight gain?
1. Employment: shift work, lack of sleep, reduced physical activity, 'hunger' hormones (cortisol, leptin, ghrelin) affected.
2. Dietary patterns.
3. Reduced physical activity.
124
What developmental factors can affect a child's risk of being obese later in life?
1. Rapid infant weight gain increases the risk of obesity.
2. Breast feeding is shown to decrease the risk of obesity.
3. Premature introduction of solid foods can increase the risk of obesity.
4. Childhood obesity is a large predictor of adult obesity.
125
What is meant by 'direct controls of meal size'?
Direct - all the factors relating to the direct contact of the food with the GI mucosa receptors.
126
What is meant by 'indirect controls of meal size'?
Indirect - metabolic, endocrine, cognitive, social and environmental factors. Indirect can override the direct controls.
127
Define satiation.
What brings an eating episode to an end.
128
Define satiety.
The inter-meal period.
129
What is the satiety cascade?
Sensory -> cognitive -> post-ingestive -> post-absorptive.
130
What is the theory behind reducing the energy density of foods?
- People to tend to keep portion sizes the same regardless of the energy density of the food.
- By reducing energy density we can keep the same portion sizes but consume fewer kcal and so keep satiety.
131
What 4 mechanisms can be used to reduce energy density?
1. Incorporation of water or air.
2. Fruits and vegetables.
3. Reducing fat (industry).
4. Method of cooking (no frying).
132
Define energy compensation.
The adjustment of energy intake following the ingestion of a particular food. The energy compensation is lower with liquids than it is with solids (except soups).
133
What is the role of alcohol in over-eating.
- Alcohol stimulates the intake of food, gives almost no satiety.
- It is efficiently oxidised.
- It adds to the total daily energy intake.
- Alcohol is associated with poor food choices.
134
Name 3 broad factors that can promote over-eating.
1. Environmental factors.
2. Psychological factors.
3. Food-characteristic factors.
135
Factors that can promote over-eating: what are examples of environmental factors?
1. Variety - greater variety can lead to overeating.
2. Portion sizes have increased significantly over the last century.
3. Distractions like watching TV promote food intake.
4. Social facilitation - going out for food with friends etc.
136
Factors that can promote over-eating: what are examples of psychological factors?
1. Stress often promotes over-eating.
2. Lack of sleep.
3. Dietary disinhibition.
4. Reward sensitivity.
137
Factors that can promote over-eating: what are examples of food-characteristics factors?
1. Macronutrient composition.
2. Energy density.
3. Liquids v solids.
138
What can cause an STI and how are they transmitted?
- STI's are caused by >30 different bacteria, viruses and parasites.
- They are transmitted predominantly by sexual contact.
139
Name the 4 main STI's.
1. Chlamydia.
2. Gonorrhoea.
3. Syphilis.
4. Trichomoniasis.
140
What is the 'ABC' list of HIV safety?
A - abstain.
B - be faithful.
C - condom use.
141
What is it important to achieve in sexual health education?
1. Involving young people effectively - they are the key decision makers.
2. Provide comprehensive and accurate information.
3. Address barriers to accessing health services.
4. Empower young people to make the life choices that are best for them.
142
What is the definition of complementary and alternative medicine (CAM)?
A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs. Healing resources other than those intrinsic to the dominant health system of a society.
143
Name some different types of CAM.
Acupuncture, Chinese medicine, chiropractic, osteopathy, herbal medicine, hypnotherapy, reflexology, homeopathy, aromatherapy etc.
144
What groups can CAM be divided into based on therapeutic similarity?
- Manual therapies.
- Ethnic medical systems.
- Mind-body/energy medicine.
- Non-allopathic systems.
145
Give examples of manual CAM therapies.
Chiropractic, osteopathy, massage, reflexology.
146
Give examples of ethnic medical CAM therapies.
Chinese medicine, acupuncture, herbal medicine, yoga.
147
Give examples of mind-body/energy CAM therapies.
Hypnotherapy, healing.
148
Give examples of non-allopathic CAM therapies.
Homeopathy, iridology, naturopathy.
149
House of lords report CAM classification: what is group 1?
There is some scientific evidence of efficacy e.g. acupuncture, chiropractic, homeopathy, osteopathy, herbal medicine.
150
House of lords report CAM classification: what is group 2?
Modalities working in a supportive capacity alongside conventional medicine, not offering independent diagnosis e.g. hypnotherapy, aromatherapy, reflexology, massage.
151
House of lords report CAM classification: what is group 3?
Traditional systems of medicine backed by historical practice only/with little evidence e.g. Chinese medicine, iridology etc.
152
Who uses CAM?
- 35-60 age group, mainly women.
- Higher income and higher educational levels.
- 60% have a chronic disease.
- Geographical variation; mainly people in the South.
153
What are the most common problems that people use CAM for?
Depression, eczema, chronic pain, IBS.
154
Give the 3 main expected outcomes of using CAM.
1. Reduction of symptoms.
2. Avoidance of medication.
3. Gaining control and improving coping skills.
155
What are 5 'push' factors for new CAM patients?
1. Lack of effective conventional treatment for their problem.
2. Concern about medication side-effects; want to avoid medication.
3. Bad past experiences, rejection of science.
4. Gullibility and naivety.
5. High (60-80%) patient satisfaction rates for CAM.
156
Give the 3 main major concerns of using CAM.
1. Unrealistic expectations.
2. Using CAM may delay conventional care.
3. General safety - unregulated practitioners and treatments.
157
What does the NHS describe as the 'Big 5' CAM?
1. Acupuncture.
2. Chiropractic therapy.
3. Homeopathy.
4. Herbal medicine.
5. Osteopathy.
158
What is the basic economic problem with regards to health services?
1. Resources are finite (scarcity).
2. The desire for services is infinite (insatiable).
3. No country can treat all treatable ill health; they don't have the capacity to do so.
4. Choice cannot be avoided (decision making).
159
What is economic efficiency with regards to health economics?
Economic efficiency is achieved when resources are allocated between activities in such a way as to maximise benefit.
160
What is economic evaluation with regards to health economics?
It is the method used to assess whether benefit is maximised - the assessment of efficiency. Are the incremental benefits of a new treatment worth the incremental costs?
161
What are the 3 types of economic evaluation?
1. Cost-effectiveness analysis.
2. Cost-utility analysis.
3. Cost-benefit analysis.
162
What is cost-effectiveness analysis?
Outcomes measured in natural units: incremental cost per year of life gained.
163
What is cost-utility analysis?
Outcomes measured in quality adjusted life years: incremental cost per QALY gained.
164
What is cost-benefit analysis?
Outcomes are measured in monetary units: net monetary benefit.
165
Health economics: what is equity?
Equity is concerned with the fairness or justice of the distribution of costs and benefits.
166
What is the problem with equity in health economics?
There are opposing views about what is fair; it is difficult to quantify and very subjective.
167
What has had the most significant effect in the reduction of TB?
Improvements in social conditions.
168
What is social class a measure of?
Occupation, stratification, social position, access to power and resources.
169
What is the inverse care law?
The availability of good medical care tends to vary inversely with the need for it within a population.
170
How can you reduce incidence rates of a disease?
Decrease risk factors e.g. primary preventions.
171
What may increase incidence rates?
Screening for a disease and identifying new cases and increasing risk factors.
172
What can decrease prevalence?
Cures and decreasing risk factors.
173
What can increase prevalence?
Screening and identifying new cases and increased life expectancy.
174
Define iatrogenesis.
An unintended, adverse effect of a medical intervention.
175
If the prevalence of a disease is high, what effect would this have on the incidence of false positives?
- Incidence of false positives would fall.
| - PPV would increase and NPV would fall.
176
Give 3 reasons for screening.
1. It can prevent suffering.
2. Early identification of the disease is beneficial.
3. Early treatment may be cheaper short and long term and improve health outcomes.
177
Why do prevention approaches favour those who are more affluent and better educated?
- These people are more likely to engage with health services.
- They are more likely to comply with treatments.
- They are more likely to have the necessary means to change their lifestyle.
178
What lifestyle changes can prevent CHD?
1. Smoking cessation.
2. Healthy eating.
3. Reduced alcohol intake.
4. Increased physical activity.
179
What has been done to help with smoking cessation?
1. Taxation.
2. Ban on smoking in public places.
3. Cessation services.
4. Public health campaigns/health warnings.
180
What has been done to help people eat healthily?
1. Public health campaigns e.g. 5-a-day.
2. Improved labelling of food.
3. Improvements in food in schools.
181
What has been done to help people reduce alcohol intake?
1. Public health campaigns - know your limits.
2. Taxation.
3. Alcohol pricing and regulation.
182
What are unmodifiable risk factors?
Things we have no control over: sex, age, ethnicity, family history, early life circumstances.
183
What are modifiable risk factors?
Things we can change:
- high blood pressure, high cholesterol, type 2 diabetes, smoking, physical inactivity, overweight, poor diet, alcohol intake.
184
What control measures can help stop the spread of diarrhoea?
- Hand washing.
- Safe drinking water.
- Safe processing and handling of food.
- Safe disposal of human waste.
185
How many units of alcohol can men have a day and in a week?
- 3-4 units a day.
| - 28 units a week.
186
How many units of alcohol can women have a day and in a week?
- 2-3 units a day.
| - 21 units a week.
187
What equation can be used to work out how many units of alcohol there are in a drink?
(%ABV x volume of drink (ml))/1,000.
188
What are the CAGE questions for alcohol dependency?
1. Have you ever fault that you should Cut down?
2. Have you ever felt Annoyed by people telling you to cut down?
3. Do you feel Guilty about how much you drink?
4. Eye opener: ever had a drink first thing in the morning?
189
What are the social implications of alcohol?
Violence, rape, driving offences, depression, anxiety etc.
190
What are some reasons for why people smoke?
Nicotine addiction, coping with stress, habit, socialising etc.
191
Smoking laws: what law was introduced in 2005?
Smoking was banned in public places.
192
Smoking laws: what law was introduced in 2007?
The minimum age to buy tobacco products was increased to 18.
193
What is patient compliance?
The extent to which a patients behaviour coincides with medical advice. It is professionally focused and assumes that the 'doctor knows best'.
194
What are some reasons for non-compliance?
- Unintentional: forgetting or not understanding.
- Intentional: the patient has their own beliefs about their condition or treatment and doesn't agree with medical advice.
195
What is non-compliance?
- Not taking medications.
- Taking medications incorrectly; wrong time, wrong dosage etc.
- Continuing behaviours against medical advice.
196
What is the doctrine of double effect?
If you administer a drug to relieve pain in doses you know may be fatal, provided your intention is to relieve pain and not to shorten life the administration is ethically okay.
197
What are the 5 focal virtues?
1. Compassion.
2. Trustworthiness.
3. Discernment.
4. Integrity.
5. Conscientiousness.
198
What is evidence based medicine about?
1. Asking focused questions.
2. Finding evidence.
3. Critical appraisal.
4. Making a decision.
5. Evaluation.
199
What is the gold standard of evidence based medicine?
Systematic reviews of RCT.
200
What are confounding factors?
Factors that can affect the validity of a study. They may be responsible for the results seen.
201
What is critical appraisal and why is it important?
Critical appraisal is about assessing validity, reliability and applicability. It is important because it means you can provide your patients with the best possible evidence and information.
202
What should a good study have?
- Randomisation of participants to interventions (reduces bias/confounding).
- Show causation rather than association.
- Have outcome measures (results) for at least 80% of the population.
203
Define systematic review.
Systematic methods are used to identify, select and analyse relevant research in order to answer a specific question.
204
Give 2 examples of non-random sampling?
1. Convenience sampling.
| 2. Purposive sampling.
205
What is NNT (number needed to treat)?
The number of patients that need to be treated in order to have an impact on one person.
206
Is a test significant if the 95% confidence interval contains zero?
No it is not significant.
207
Why is a good doctor-patient relationship important?
- Better health outcomes for the patient.
- Improved patient compliance.
- Improved patient satisfaction.
- Reduced risk of malpractice.
208
Is there a relationship between stress and illness?
Yes - the stress-illness model. When an individual is stressed they are more susceptible to disease due to psychological and physiological changes.
209
Define stroke.
Rapidly developing focal neurologic signs of cerebral function. Lasting >24 hours. There is no apparent cause other than vascular origin. Can be hemorrhagic or ischemic.
210
Give 5 risk factors for stroke.
1. Age.
2. Sex.
3. Drinking alcohol.
4. Smoking.
5. Hypertension.
211
What are the problems with sending patients home early from hospital?
Patients go home with a higher dependency. They may need carers and social support and if this fails you often get readmission.
212
How can we prevent recurrent hospital admission?
1. Support discharged patients.
2. Support chronic disease management.
3. Community care services.
213
What type of study uses routinely collected data to show trends and to generate hypotheses?
Ecological.
214
What type of study divides a population into those with the disease and those without and collects data at a single point in time?
Cross-sectional study.
215
What type of study matches people with a disease to those without for age, sex, habits, class etc?
Case-control study - retrospective.
216
What type of study studies a population to see if they're exposed to the agent in question and if they develop the disease?
Cohort study - prospective.
217
Give 3 advantages of an ecological study.
1. Uses routine date and so is quick and cheap.
2. Few ethical issues.
3. Useful for generating hypotheses.
218
Give 3 disadvantages of an ecological study.
1. Cannot show causation.
2. Inconsistency in data presentation.
3. Bias - variation in diagnostic criteria.
219
Give 4 advantages of a cross-sectional study.
1. Can give rapid insight into events within a population.
2. Few ethical issues.
3. Good for generating hypotheses.
4. Quick and cheap.
220
Give 3 disadvantages of a cross-sectional study?
1. Prone to bias.
2. No time reference.
3. Could be reporting medical oddities.
221
Give 3 advantages of a case-control study?
1. Quick - results can be obtained quickly (retrospective).
2. Cheap.
3. Usually a small number of people required to produce statistically significant results.
222
Give 3 disadvantages of a case-control study?
1. Retrospective date may be unreliable - selective memory.
2. Shows association but not causation.
3. Prone to selection and information bias.
4. Cannot calculate incidence.
223
Give 3 advantages of a cohort study?
1. Can calculate incidence and so can find relative and absolute risk.
2. Reduced chance of bias - exposure measured before disease develops.
3. Can distinguish causes from associated factors.
224
Give 3 disadvantages of a cohort study?
1. Expensive - long time and large population.
2. Causation cannot be calculated - control study is needed for this.
3. Often difficulties with follow-up.
225
Give 3 advantages of a RCT?
1. Confounders are equally balanced.
2. Blinding minimises bias.
3. Statistical tests are easier when confounders are minimised.
226
Give 4 disadvantages of a RCT?
1. Expensive - large populations.
2. Poor compliance can mean statistical tests lose their power.
3. Volunteer bias.
4. Ethical difficulties in withholding treatment from control groups.
227
What does the presence of bias in a set of results imply?
The results of the study are not accurate.
228
True or False: if the confidence interval contains 1 the results are statistically significant.
False - the results are not statistically significant if the CI contains 1 at the p
229
Will the standard error in a set of results be big or small if the precision is good?
There will be a small standard error.
230
Give an example of a primary prevention.
Vaccination e.g. MMR vaccine.
231
Give an example of a secondary prevention.
Screening programmes e.g. Breast cancer screening.
232
Give an example of a tertiary prevention?
Reducing risk factors and changing lifestyle e.g. In copd pulmonary rehabilitation and smoking cessation are types of tertiary prevention.
233
How can you calculate the NNT?
1/risk difference
234
What is nominal data?
A qualitative classification of data - a naming system.
235
What is ordinal data?
When data has numerical scores existing in order.
236
What is binary data?
Data that can only take one of 2 possible states. E.g. alive or dead.
237
What is discrete data?
Data with a finite number of values e.g. Number of people living in a house.
238
What is continuous data?
Data that can take any value e.g. height.
239
What is linear regression used for?
Estimating mean differences between groups.
240
What is logistic regression used for?
Binary outcomes. It models an odds ratio.
241
What is poisson regression used for?
It models rate ratios.
242
What is cox regression used for?
It models hazard ratios.
243
Define morbidity.
Suffering from a disease.
244
Define mortality.
The number of deaths per year for a specified disease.
245
What is the medicalisation hypothesis?
Professionals tend to see problems in terms of their own profession. Doctors therefore look at problems medically. Some conditions that seem medical can be a product of social forces e.g. mental illness can be seen medically when the route of the problem may be socially related.
246
Define iatrogenesis.
Unintended side effects caused by therapeutic intervention e.g. making someone more ill when trying to treat them.
247
Explain the concept of concordance in healthcare.
Patients are viewed as equals in care. They are involved in decision making about their treatment.
248
Behavioural change: what is the nudge theory?
Changing the environment to make healthy option an easier choice. E.g. making healthy food cheaper and more accessible.
249
If the prevalence of a disease is low, what affect does this have on false negatives?
- The number of false negatives will decrease.
| - NPV will increase and PPV will decrease.
250
When would a screening service look at improving the sensitivity of a test?
When the effect of missing someone with the disease and not treating them is worse than the trauma a false result will cause. The number of false negatives is minimised.
251
What is the 'prevention paradox'?
The idea that a large number of people at small risk of a disease may contribute more cases than a small number of people who are at greater risk.
252
What is the population approach to prevention?
Targeting all individuals with the aim of reducing the risk for everyone. It recognises that the low risk majority may contribute a lot of cases and it reduces social inequalities.
253
What is the high risk approach to prevention?
Targeting only the individuals who are a high risk. It is accepted by society - treating those outside 'normal levels' and it is cheaper than the population approach.
254
What are the disadvantages of the high risk prevention approach?
- It favours those who are better educated: more likely to engage with NHS services and comply with treatments.
- It can be difficult to identify those who are at high risk.
255
What are the disadvantages of the population approach?
- Expensive.
| - Public concerns over treating well people unnecessarily.
256
What is a p value?
It tells us the probability of the results being due to chance.
257
Define clinical significance.
The results are significant enough to be worthwhile clinically. They will have a genuine effect on day to day life.
258
Define statistical significance.
The results are used to accept or reject the null hypothesis. They are not necessarily clinically significant.
259
What are some reasons for why people start smoking?
Influence from parents/siblings/neighbourhood they grow up. Peer pressure, wanting to fit in. 'Solution' to stress.
260
What law was introduced in 1965 to encourage people to stop smoking?
Smoking advertisements on television were banned.
261
Describe the epidemiology of smoking.
- Married people are less likely to smoke.
- Unemployed people are more likely to smoke.
- There is a link between poverty and smoking; people from lower socio-economic backgrounds are more likely to smoke.
262
State two potential psychosocial implications of infertility?
1. Depression.
| 2. Relationship breakdown.
263
State a reason why infertility might be increasing in the general population?
People are delaying having a family until they are older. There is a higher incidence of STI's too which can lead to infertility.
264
What are the outcomes of IAPT?
Lower socio-economic groups are now more likely to access talking treatments than before. But the well-off are still paying disproportionately more for private therapy.
265
What can doctors do to help people with CMHP's?
1. Provide user-friendly, accessible, information and advice to disadvantaged groups.
2. Signpost patients to appropriate advice and support services.
266
What type of stressors would elicit the fight of flight response?
External acute stressors.
267
How is the fight or flight response activated?
The hypothalamus activates the sympathetic nervous system and also the adrenal medulla (Na, Ad) and adrenal cortex (cortisol). There is activation of some organs and inhibition of others.
268
Give 3 reasons why obesity is such a big issue.
1. Its widespread.
2. Its prevalence is increasing.
3. Its consequences are costly.
269
What can twin-studies tell us about the aetiology of obesity?
Twin and family studies suggest a high degree of genetic contribution to body mass.
270
What are the 7 key domains for energy balance?
1. Food environment.
2. Food consumption.
3. Individual activity.
4. Societal influences.
5. Individual biology.
6. Individual psychology.
7. Activity environment.
271
What are the 2 main ways in which STI's can be prevented?
1. Counselling and behavioural methods e.g. sex education, safer-sex counselling, interventions targeted at vulnerable populations.
2. Barrier methods e.g. condom use.
272
Give 3 barriers to improving sexual health services.
1. Lack of funding and resources.
2. Influences of religion.
3. Personal attitudes of staff.
273
What is consequentialism (utilitarian) ethics?
An act is evaluated in terms of its consequences. Acts to maximise good.
274
What are the challenges of consequentialism?
1. Minorities may be treated unfairly to promote the happiness of the majority.
2. Determining whether a consequence is good could be subjective.
3. Is it okay to carry out ethically questionable research to maximise the welfare of society?
275
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.
276
Categorical imperatives are a version of deontology. What are they?
A categorical imperative is 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 situation.
277
What are the challenges of deontology?
Consequences aren't looked at. Duties can conflict.
278
What are virtue ethics?
Focuses on the character of the person, integrating reason and emotion. An action is only virtuous if the person has the right mind set. Virtues are acquired.
279
What are the 5 focal virtues?
1. Discernment.
2. Conscientiousness.
3. Compassion.
4. Trustworthiness.
5. Integrity.
280
5 focal virtues: define discernment.
The ability to judge well.
281
5 focal virtues: define integrity.
Being honest and having good moral principles.
282
5 focal virtues: define compassion.
Showing concern for others.
283
5 focal virtues: define conscientiousness.
Being thorough, careful and vigilant. Wanting to complete a job as well as you can.
284
5 focal virtues: define trustworthiness.
The ability to be relied on and trusted.
285
What are the challenges of virtue ethics?
Virtue ethics don't focus on consequences. Virtues are culture specific and too broad for practical application. It is not always clear how to solve a moral dilemma using virtue ethics.
286
What is capacity?
The patient's ability to make a decision.
287
What are the 4 questions that should be asked when assessing capacity?
1. Does the patient understand?
2. Can the patient retain the information?
3. Can they use the information to weigh up options and make a decision?
4. Can they communicate their decision?
288
What is the age of consent for medical treatment?
16.
289
What is Gillick/Fraser competence?
If a child under 16 is assessed as Gillick/Fraser competent they can make their own decisions about their care without parental permission.
290
A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What needs to be considered when making decisions?
1. Does this patient have capacity?
| 2. Are there any child protection issues?
291
A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What are 2 ethical problems in this case?
1. Underage sex.
| 2. Under 16, are they gillick competent?
292
A gentleman has made some nonspecific arrangements about his end-of-life management. His health deteriorates and the managing team consult family in making care-related decisions. According to the mental capacity act, why should family be consulted?
Family may be able to help the managing team better aware of the patient’s values and preferences when they have capacity. It can help with care-related decisions.
293
You are a medical student on a ward and you are concerned about the way one of the doctors is treating a patient. He tells you to examine the patient’s abdomen, but fails to ask for her consent. Which of the 4 ethical principles is being compromised here?
Autonomy is being compromised - the doctor is not respecting the patients decision. In this situation you would ask the patient for consent before carrying out the examination.
294
One of your fellow medical students turns up to ward rounds smelling of alcohol and you are concerned about their fitness to practice. Explain your course of action using the principle of deontology.
The duties of a doctor is a deontological document. Deontology is about the worthiness of the act. Turning up to work drunk is putting patients at risk; you are not protecting the health of patients and won't be able to provide a good standard of care.
295
You are walking home one day and a lady recognises that you are a doctor. She comes over to you and says you’ve recently been treating one of her neighbours and she wants to know how he is. She asks if you can tell her anything about his condition as she is really worried. What is your course of action?
You listen to the lady and understand her concern. However you can not tell her anything and you can not even reassure her as this would be breaking confidentiality. You could advise the lady to contact her neighbour herself and you apologise that there isn't anything you are able to say.
296
Can you think of reasons why you may not mind if the test is not particularly sensitive?
This may be acceptable where the consequences of missing the disease are minimal e.g. a disease with slow progression where delayed diagnosis was of no concern. Often screening tests with regular rounds e.g. when people are screened every 3 years have low sensitivity.
297
Why would a screening service look at improving the specificity of a test?
When the follow up diagnostic test is expensive or carries some risk so you want to minimise the number of disease free people having unnecessary procedures. Minimising False Positives may also be desirable where significant anxiety may be caused by a positive test result, or where there is significant stigma associated with the disease for which you are screening.
298
Can you think of reasons why you may not mind if the test is not particularly specific?
This may be acceptable where the condition creates little anxiety, and the follow on diagnostic testing is quick, cheap and safe.
299
What are deductive ethical arguments?
Using one general ethical theory and applying it to all medical problems.
300
What are inductive ethical arguments?
Using settled medical cases to generate theories or guides to medical practice.
301
What is the BMI range of someone who is overweight?
25-30 kg/m^2.
302
Give 2 factors in the economic environment that can lead to being overweight.
1. Unhealthy food tends to be cheaper.
| 2. There is more advertising for unhealthy food because it is produced by large manufacturers.
303
Give 2 factors in the cultural environment for being overweight.
1. Social - eating out more.
| 2. Family influences - if your family eat unhealthily you're likely to as well.
304
What is the first line of treatment for obesity?
Encourage people to improve their diet and to do more exercise to lose weight.
305
Give 2 social consequences of being overweight.
1. Depression and isolation.
| 2. Unable to work, especially if the job is very demanding.
306
Give 2 advantages of a systematic review?
1. Can prove causation.
| 2. Compares similar studies.
307
Give 2 disadvantages of a systematic review?
1. Time consuming.
| 2. Expensive.
308
Define opportunity cost.
The benefits forgone from investing and allocating resources in one thing but not in something else.
309
How do you calculate incremental cost?
New cost - old cost
310
How do you calculate the effectiveness ratio?
Incremental cost (new-old) / difference QALY (new-old).
311
What is an obesogenic environment?
An environment that encourages people to eat unhealthily and not do enough exercise.
312
Give 3 physical characteristics of an obesogenic environment.
1. Increased car culture.
2. Lifts.
3. TV remotes.
313
Give an economic characteristic of an obesogenic environment.
Expensive fruit and vegetables.
314
Give a socio-cultural characteristic of an obesogenic environment.
Family eating patterns.
315
Describe the ready, steady, stop process for quitting smoking.
- Ready: be prepared and aware, understand the process.
- Steady: set a quit date, throw away ashtrays and lighters etc.
- Stop: set a plan for the day, avoid triggers and reward yourself.
316
Give 5 signs of foetal alcohol syndrome.
1. Growth abnormalities.
2. CNS abnormalities.
3. Learning difficulties.
4. Poor socialisation skills.
5. Low birth weight and small head circumference.
317
Give 2 reasons for an increase in childhood obesity.
1. Technological advances - video game culture. Children exercise less.
2. Cheaper unhealthy food and increased promotion aimed at children.
318
Give 2 reasons for screening.
1. Identifying a disease early can improve prognosis.
2. Treatment at an early stage may be cheaper and so save money long term.
3. Reduces mortality and morbidity.
4. Reassurance for those with a negative test result.
319
What is the most important statistical information you would need to give a patient who has a positive screening test result.
The PPV, the proportion of people with a positive result who do actually have the disease.
320
How much alcohol is there in one unit?
8g or 10ml.
321
Give an example of a one unit alcoholic drink.
Small glass of wine, half a pint of beer.
322
Name 3 liver conditions associated with chronic alcoholism.
Cirrhosis, fatty liver disease, alcoholic hepatitis.
323
Name 4 methods of reflecting on medical practice.
1. Audits.
2. Portfolios.
3. Revalidation.
4. 'Would you recommend to a friend?'
324
What 3 things may be considered in bio-ethics?
1. Abortion.
2. Organ donation.
3. Euthanasia.
325
What does PICO stand for?
P - patient problem or population.
I - intervention.
C - comparison.
O - outcome.
326
What is the analysis of data in a systematic review called?
Meta-analysis.
327
What can the government do to encourage healthy behaviour?
Make healthy food cheaper and more appealing. Promote exercise - subsidise gym costs etc.
328
What can the government do to discourage unhealthy behaviour?
Bring in taxes e.g. the sugar tax. Reduce advertising for unhealthy products.
329
Give 6 of the Bradford Hill criteria that provide evidence for causation.
1. Consistency.
2. Reversibility.
3. Biological plausibility.
4. Strength of association.
5. Temporality - cause before disease.
6. Dose-response.
330
What is health behaviour?
Behaviour aimed at preventing disease e.g. eating healthily, exercising etc.
331
What is illness behaviour?
Behaviour aimed at seeking remedy e.g. going to see a doctor.
332
What is sick role behaviour?
Behaviour aimed at getting better e.g. compliance and resting.
