Study Guide Flashcards
Cancer prevalence in developing vs. the developed world
- Cancer is a leading cause of morbidity and mortality worldwide
- 70% of deaths occur in low- and middle-income countries with around ⅓ of deaths due to the
Opioid availability and which countries have met their opioid needs or have NOT met their opioid needs (only a few countries that have met or exceeded their opioid needs
Met: US
Unmet: Haiti, Nigeria, India/Indonesia, Russia, China, Uganda
Of these countries talk about how much of their opioid needs: be ready to rank countries based on their opioid availability (Nigeria, India, Uganda, Indonesia, Haiti, Australia, US, UK)
Ranking based on need Haiti (<1%) Nigeria (0.2%) India/Indonesia (4%) Russia (8%) Uganda (11%) China (16%)
Prevalence of cancer in developing words
Lower or higher
Lower
Prevalence of NCDs in the developing world
Lower or higher
Fewer NCDs (which are cancer risk)
Death rate in developing world
low or high
VERY HIGH death rates
Which has higher NCD’s developed or developing?
Developed world has higher NCDs (total) but developing world NCDs are growing at extremely high rates
Disparities in incidence of cancer and cancer survival: some places have lower incidence of cancer but higher death rates and vice versa. Have some idea of which continents have these types of disparities
Continents
- Africa
- SE Asia
- E Medit
Disparities in incidence of cancer and cancer survival: some places have lower incidence of cancer but higher death rates and vice versa. Have some idea of which countries have these types of disparities
COUNTRiES
- Libya (40%) to Norway (70%) for cervical cancer
- Jordan (16%) to USA (90%) for AML
Common barriers to opioid or morphine availability (4)
- Doctors get no palliative training
- Legislators or police oppose importation or make prescribing difficult
- “Opiophobia” - doctor unwillingness or fear to prescribe medication
- Pharma companies uninterested in marketing generic morphine (cheap=low profit)
Characteristics of oral morphine use
Diluting syrup with morphine so the concentration is not enough to get someone high or dependent but it effectively relieves pain
Can’t even get addicted to it if you take a lot
Structure of Uganda Morphine Program
- Who can administer
- Details of Program
Who can administer
Nurses with special training
Details of Program
AIDS patients had been dying screaming from cryptococcal meningitis or Kaposi’s sarcoma.
Allowed nurses with special training to prescribe morphine
Outside a private charity overseen by the government distributed oral morphine free of cost with two strengths. (0.5g or 5g per 500mL). This was so people who have to drink gallons to get high.
Risk factors for cancer in the developing world (10)
- HPV/Hepatitis/HIV (Communicable diseases)
- Tobacco/alcohol
- Obesity/Sedentary lifestyle
- Diet low in fruit/vegetables
- Occupational hazards
- UV exposure
- Urban air pollution
- Indoor smoke
- Cultural behaviors like skin bleaching
- Late presentation (caused by distrust)
Difference between the 2 components of early detection
Screening vs. Early detection
Screening
- Identifying individuals with abnormalities suggestive of a specific cancer or pre-cancer who have NOT yet developed symptoms and refer them for diagnosis/treatment.
- This is a more complex public health intervention compared to early diagnosis
Early detection
Programs designed to reduce delays/barriers to care to access treatment in a timely manner.
When is screening effective
when correct test are implemented effectively and are linked with other steps in the screening process.
Describe screening for cervical cancer in low-income areas
Visual inspection with acetic acid (VIA) for cervical cancer in low-income settings
Examples of screening
- Visual inspection with acetic acid (VIA) for cervical cancer in low-income settings
- HPV testing for cervical cancer
- PAP cytology test for cervical cancer in middle- and high-income settings
- Mammography screening for breast cancer in settings with strong or relatively strong health systems
Three steps that must be integrated and provided for early detection
Awareness and accessing care
Clinical evaluation, diagnosis, and staging
Access to treatment
T/F Early diagnosis means less morbidity, less expensive treatment, greater probability for surviving, and more likely to respond to effective treatments.
True
Early diagnosis means less morbidity, less expensive treatment, greater probability for surviving, and more likely to respond to effective treatments.
T/F
Early screening is not relevant in all setting and the majority of cancers.
False
Early screening is relevant in all setting and the majority of cancers.
What is the “See and Treat” approach for screening women,
4 benefits
An alternative which would screening women and simultaneously treating them if they have any abnormality
- Cheap and easy to operate equipment
- Specialist surgical skills not required
- Rare complications
- Women diagnosed with lesion are not lost to follow-up
Approaches to cervical cancer for high income (3)
- Pap smear for screening requires follow up and requires a skilled healthcare professional who knows how to evaluate results
- Surgical conistation for treatment that requires hospital admission
- Mammogram machines- high resource areas
Approaches to cervical cancer for low income (2)
- VIA (visual inspection with acetic acid)- use vinegar to identify normal cell spots→ doesn’t require follow up and treatment can be completed on the same day
- Loop cryotherapy for treatment- using a rod with liquid nitrogen to get rid of abnormal growths
Possible detection and screening protocols best suited for low-resourced setting
In low resource settings, use a “See and Treat” methodology→ screen, diagnose, and treat them at the same time since follow up may not be as feasible
Possible detection and screening protocols best suited for well-resourced vs. low-resources
Consider Pap Smear (High) vs. HPV vaccine (high)
VIA method (low resource) vs. contraception + education
What are the most important risk factors for cancer in the world
Tobacco
22% of cancer
Common symptoms for HIV and AIDS
- Cough
- Diarrhea
- Anorexia, Nausea, Vomiting
- Pruritus - dry skin, drug reactions, scabies, folliculitis
- Malaise, Weakness, Pyrexia
- Psychological Distress
What are the 4 ways that stigma manifests for people with HIV
- Physical Stigma - Isolated, shunned, neglected and forced to live apart because of violence
- Social Stigma - Voyeurism, social death, loss of standing in society
- Verbal Abuse - Gossip/taunting
- Institutionalized Stigma - Barred from jobs, scholarships, visas, health care, harassed by police
Burden of pediatric HIV now and the historic burden; compare current vs. past burden for kids with HIV
Current Burden: 160K in 2016
Historic Burden: 300K in 2010
Comparison: The burden is decreasing but still 400 children are infected every day due to
90% mother to child transmission, sexual abuse, child marriage, iv drug abuse, transfusions, unsterilized needles
Of the children infected with HIV whats the most common way
90% mother to child transmission
EC:
Another viral illness that is fatal that also requires significant palliative care when it occurs
Rabies - 100% fatal
Acute encephalomyelitis
Know 5 different types of paralysis
- Quadraplegia - affects all four limbs and trunk as result of spinal injury above the thoracic vertebra
- Paraplegia - affects the loss of movement in both legs from injury located below the thoracic vertebra
- Monoplegia - caused by spinal injury and affects just one limb
- Diplegia - affects symmetrical parts of the body normal both arms or two sides of the face
- Hemiplegia - affects only one side of the body (usually result of a stroke)
Quadraplegia
affects all four limbs and trunk as result of spinal injury above the thoracic vertebra
Paraplegia
- affects loss of movement in both legs from injurt located below the thoracic vertebra
Monoplegia
- caused by spinal injury and affects just one limb
Diplegia
- affects symmetrical parts of the body normal both arms or two sides of the face
Hemiplegia
- affects only one side of the body (usually result of a stroke)
Intrinsic risk factors for falls (11)
- Previous falls history
- Age
- Gender
- Living alone
- Polypharmacy
- Multiple comorbidities
- Impaired mobility
- Psychological status
- Nutritional deficiencies
- Cognition
- Visual impairments
Extrinsic risk factors for falls (6)
- Poor lighting
- Slippery floors
- Uneven surfaces
- Cluttered living spaces
- Inappropriate walking aid
- Poor footwear and clothing
Non-modifiable risk factors for falls
- Age
- Sex
Delirium vs. Dementia
Neuron status
Delirium - impaired neurons
Dementia - death of neurons
Delirium vs. Dementia
Onset
Delirium- acute and dramatic
Dementia - gradual and slow
Delirium vs. Dementia
Amnesia
Delirium - global amnesia/complete loss or orientation and short term memory
Dementia - selective amnesia - attention loss more in long term
Delirium vs. Dementia
Causes
Delirium - infectious, metabolic, toxic, trauma, respiratory
Dementia - idiopathic (alzheimer), residual
Delirium vs. Dementia
Misdiagnosis
Delirium - acute psychoses + agitated mania
Dementia - pseudo-dementia, diagnosed with dementia when its depression
Delirium vs. Dementia
Prognosis
Delirium - good if on time and (reversible)
Dementia - poor (irreversible)
Delirium vs. Dementia
Treatment
Delirium - treat cause of delirum
Dementia - cholineserase inhibitors
Describe Terri Schiavo
The media portrayed her case to be about assisted suicide when in reality she just wanted her feeding tube removed. In court, her parents advocated against removing her tube, while her husband pushed to keep it.
5 types of spontaneous miscarriage
Match
- Threatened - abdominal pain or bleeding in the first 20 weeks, closed cervix o and no fetal tissue is passed
- Inevitable - abdominal pain or bleeding in the first 20 weeks, open cervix o and no fetal tissue is passed
- Incomplete - abdominal pain or bleeding in the first 20 weeks, open cervix o and fetal tissue is passed
- Complete - abdominal pain or bleeding in the first 20 weeks, closed cervix o and complete passage of fetal parts and placenta as the uterus contracts
- Septic - Infection of uterus during miscarriage that causes fever and chills usually due to Staph. Aureus, open and purulent cervical o with discharge and tenderness, no fetal tissue or may be incomplete
Spontaneous miscarriage:
Threatened
- Cervix- open/closed
- Fetal tissue
- Other
- Closed cervix
- No fetal tissue
- N/A
Spontaneous miscarriage:
Inevitable
- Cervix- open/closed
- Fetal tissue
- Other
- Open cervix
- No fetal tissue
- N/A
Spontaneous miscarriage:
Incomplete
- Cervix- open/closed
- Fetal tissue
- Other
- Open cervix
- Fetal tissue
- N/A
Spontaneous miscarriage:
Complete
- Cervix- open/closed
- Fetal tissue
- Other
- Closed cervix
- Complete fetal parts and placenta
- N/A
Spontaneous miscarriage:
Septic
- Cervix- open/closed
- Fetal tissue
- Other
- Open + purulent cervix
- No fetal tissue or incomplete
- Infection in uterus due to Staph with discharge
Things to not to say to someone that has lost a baby to miscarriage
- It wasn’t a proper baby.
- You’ll be fine, you’ll get over it.
- At least you know you can get pregnant, you can just try again.
- In my day we just treated it like a heavy period.
- It’s nature’s way.
- What did you do to make it happen?
- It wasn’t your time.
- Everything Happens for a reason.
What kinds of questions kids ask that may indicate incomplete understanding:
Irreversibility-
Irreversibility - knowing dead things will not live again
- How long do you stay dead?
- When is my dead pet coming back?
- Can you “undead” someone?
What kinds of questions kids ask that may indicate incomplete understanding:
Finality or nonfunctionality -
Finality or nonfunctionality - knowing all life-defining functions end with death
- What do you do when you’re dead?
- Can you see when you’re dead?
- How do dead people get sad or eat?
What kinds of questions kids ask that may indicate incomplete understanding:
Universality
Universality - knowing all living things must die
- Does everyone die?
- Do child die?/Do I have to die?
What kinds of questions kids ask that may indicate incomplete understanding:
Causality
Causality - having a realistic understanding of the causes of death
- Why do people die?
- Do people die because they’re bad?
- Can someone wish someone dead?
*Treatment of burns
- Extinguish flames
- Stop the burning by removing clothes and irritating with water
- Use cool water to reduce temperature of the burn
- Wrap patient in clean cloth and transport
- Pain control
- Fluid/Electrolyte Balance
- Infection
- Debridement
- Nutrition
- Skin Graft
- Physiotherapy/OT
Most important thing a doctor or care responder should do in the acute management of a burn victim
Remove the patient’s clothes and irrigate the body with cool water (if emergency); treat the pain
Burden of burns: different types of burns for men vs. women, different overall burden for men vs. women
Women are (slightly) more likely to suffer from burn injuries than men due to the amount of time they spend cooking/working near stoves and open flames Men are most likely to be burned at work. Women are more likely to be burned in the home.
Long history of burn treatment with the differences in specialized burn treatment that we did not find out for a long time; as a formal discipline its relatively new
- Burn management has been relatively the same for thousands of years: feed the patient, keep them clean, treat the pain.
- Speciality and formal training is fairly recent, but relies on the same basic principles.
Long term consequences for burn victims after the burns have healed
- Pain
- Disfigurement
- Disability
- Infection (cellulitis, pneumonia, UTIs, sepsis)
- Compromised lung infection
- Anemia
- Compartment syndrome (especially w/ electric burns)
- DVTs
- Keloids
- Blinding
- Ostracization and isolation
- Family abandonment
- Psychological Trauma (High risk for suicide, social isolation, child abandonment and poverty)
T/F Clock genes that control circadian rhythm are the same in drosophila and humans
T
The 2 main clock genes are the same in drosophila and humans
T/F
REM only occurs in warm blooded animals but we become cold blooded during REM
REM only occurs in warm blooded animals but we become cold blooded during REM
Light Non-REM
Aroused state where we go to deep non-rem in 2-5 mins
Deep Non-REM
The amount you need depends on age and decreases the older you get.
Sleepwalking is when Deep Non-REM disturbs into Light Non-REM and the spinal cord memory takes over
Sleepwalking occurs when?
Sleepwalking is when Deep Non-REM disturbs into Light Non-REM and the spinal cord memory takes over
T/F
Sleepwalking is when REM disturbs into Deep Non-REM and the spinal cord memory takes over
Sleepwalking is when Deep Non-REM disturbs into Light Non-REM and the spinal cord memory takes over
REM
Cold blooded and paralyzed with most REM in the 2nd half of the night and causes us to wake up cold
Why do we bundle babies when they sleep
Babies sleep 20 hours a day with 50% in REM which is why we bundle them up so they stay warm
How to use melatonin
You are supposed to take it at the same time every day 30 mins before you want to sleep.
List 4 ways to reset your circadian rhythm everyday
- Melatonin
- Blackout curtains
- 1500 lumens of Full spectrum light bulb and timer/alarm (15 minutes)
- Blue light/protector/filter for smartphones and ipads
T/F
Spinal cord memory takes over when sleep walking
T
Spinal cord memory takes over when sleep walking
Homecare services
advantages and disadvantages of each?
Pros:
Cost Effective
Better Care- more people improve
More control over personal schedule (more flexibility with visitations etc)
Culturally Responsive
Familiarity
Family members may be paid to be caregivers
Cons
Don’t have 24/7 access to providers
Caregiver burnout (Skilled nursing care is the only available services; rest may fall to family members)
Remote locations
Government restrictions
Lack of supervision of healthcare workers
Long term care facilities:
advantages and disadvantages of each?
Pros:
High accessibility and supervision of staff
Less Caregiver burden- families don’t have to be as involved
More advanced facilities
Cons
Less familiarity/ family can’t be as involved
Not as flexible
More expensive
Know description and key features
Global Access to Pain Relief Initiative
- Joint initiative with WHO and partners assessing target 8 of World Cancer Declaration: effective pain control will be universally available by 2025
- Works to ensure access to pain relief and PC is prioritized within the policies of key health agencies
- Works to improve regulation of drugs
Know description and key features
End of life Nursing Education Consortium (ELNEC)
- Core curriculum to educate nurses in end of life care and to cater to pt’s unique needs
- ELNEC launched international curriculum and training sessions
Know description and key features
Hospice Palliative Care Association- South Africa
- Membership org for hospices in South Africa
- Aimed at support and capacity building
1. Butterfly Box- shop designed to raise awareness
2. Lace up for Cancer- race for fundraising and awareness
3. Fives for Hospice- tournament to raise awareness and funds
Know description and key features
Cecily Saunders International
British nurse who founded modern hospice movement and emphasized role of PC in modern medicine
Goal: research and PC training, public awareness
Know description and key features
International Network for Cancer Treatment and Research
- Addressing increasing burden of cancer in developing countries
- Focuses on: international collaboration, building capacity in low resourced settings
- Formed in Kerala and Jaipur, India: early detection, tx, and PC of cancer
Acquired vs. Innate Fears
Innate Fears: pain, dying, being alone, physical proximity, bleeding, novel places, confined spaces, strange things, bitter/nasty food, being stared at, unpleasant odors, loud sounds
Acquired: being buried alvoe, heights, clowns, needles
Difference between anxiety and fear:
Fear: unpleasant emotional response caused by anticipation or awareness of specific danger
Anxiety: prompted by generalized, non-specific threats to ‘self’, motivates hypervigilance and retention of proximity to the perceived threat
Fear encourages what natural mechanism
Encourages avoidance from the threat, produces physiological state of “fight or flight”
Types of anxiety issues (5)
- Terminal agitation
- Thenatophobia
- Panic attacks
- Stress and stress disorders
- PTSD
Terminal agitation
distressing form of delirium in dying patients because of opioid toxicity or withdrawal from drugs, pain, fever, sepsis, hypercalcemia, psychological elements
Thenatophobia
the fear of death
Panic attacks
discrete period of intense fear where 4+ symptoms develop abruptly (i.e. feeling faint, rapid heart beat, wobbly legs, choking, sense of dread); peaks within 10 minutes
Stress and stress disorders
state of mental or emotional strain or tension resulting from adverse or very demanding circumstances
PTSD
caused by fear of recurrence of illness
Objective vs. subjective caregiver burden
Objective Burden:
- Constraints on social activities
- Negative effects on family life
- Extra costs, lower earnings
- Time spent performing ADL or medical care
- Doctor’s waiting rooms/ER
Subjective Burden:
- Anger, grief, guilt, exhaustion, anxiety, depression, fear, illness
“Caregiver Syndrome”
A term widely used among physicians but does not have ICD10 codes
Can’t properly diagnose it as this because of lack of code, also physicians aren’t asked by doctors if they are experiencing caregiver stress
If it were given a clinical name caregivers would be better able to receive appropriate resources and have validation of their feelings
US bereavement
The United States has had a shift towards more nuclear, heterogenous, secular society where bereavement and mourning are seen as highly individualized, private, and death of an individual is unnoticed by society at large; there is less sense of community and disengagement of the elderly too
Because of macroinstutions like the law, work place, funeral homes, medical care system most deaths occur in the hospital or nursing home and how the body is handled is mandated by institutional requirements and health profession norms
Bereavement in collectivist society
In collectivist cultures there is still emphasis on kinship, joint households and religion
Advantages:
Death of individuals still affects an entire community, social structures still present to provide support
Able to practice mourning rituals openly- shared way of processing and responding to death
Challenges:
- This can please unrealistic expectations especially on women whose spouses have passed away (i.e. not being able to leave the house for a certain amount of days, not allowed to re-marry, in some cultures expected to ritual suicide)
- Most of these cultures may not have proper institutional support when it comes to dealing with death and loss → makes it difficult when a person’s individual response to death is different than the community response and those bereavement methods do not align
Challenges to bereavement in a place like the United States that is very culturally heterogeneous
- Ethnic minorities may undergo acculturation and social mobility which results in altered beliefs and behaviors → result of stress and pressure to acculturate into new dominant culture
- We do not have the social institutions available for a lot of refugee and immigrants to follow their traditional process of bereavement (i.e. Latinos in America may not have access to Spanish-speaking clergy that can help them organize expected religious rituals)
- Funeral homes and healthcare facilities don’t understand or tolerate a lot of
Challenges for drug addicts needing palliative care
a. Their pain is often undertreated:
- They have high tolerance to higher medication levels
- Physicians fear patient is abusing treatment so they may underprescribe
- Doctors have to justify levels of medication given that would otherwise be suspect to FDA regulations
b. Have to carefully monitor and assess patients
c. Need to utilize multidisciplinary team approaches
d. Encourage participation in recovery programs
e. Utilize pill counts and urine toxicology screenings
Universal consequences of Alcoholism and Addiction (5)
- Psychological dependence
- Tolerance
- Withdrawal (acute and post-acute)
- Loss of control
- Progressive physical, psychological, social & spiritual damage
Reducing fall risks
- A good shoe
- Correct use of walking aids
- Removing/avoiding risks in home
- More exercise (can help address fear of falling, keeps muscle strong and prevents joint aches) and sun exposure (low Vitamin D is a risk)
SPIKES
- Setting-prepare for the meeting
- Perception-assess the patient’s understanding
- Invitation: ask permission to engage in conversation about a sensitive topic (demonstrates respect)
- Knowledge: the information the team wishes to convey
- Empathy: helping the patient see through the fog of his/her emotions and responding w/ empathy
- Strategy/Summary: summarize what was discussed
Advanced care plans types (7)
- Living will (1969)
- Patient Self-determination Act (1991)
- Durable Power of Attorney & Healthcare Proxy (2nd gen)
- Medical directive (1989)
- Values History (1988)
- FIve wishes directive (1998)
- Lifecare Advance Directive (2008)
Living will (1969):
allows individuals to have financial and medical control while alive, but non-communicative
Patient Self-determination Act (1991):
required hospital to inform patients of all options
Durable Power of Attorney & Healthcare Proxy (2nd gen):
appoint someone to make decisions on your behalf
Flexible and adaptive solution → Challenging to communicate what you want to a proxy, next-of-kin decisions
Medical directive (1989):
presented 6 common medical scenarios and interventions for individuals to consider and then make medical decisions; usually not trained to do so
Values History (1988)
focus from specific treatment to patient’s values and goals
Five wishes directive(1998):
- Who I want to make decisions for me
- What kind of treatment do I want or not want
- How comfortable I want to be
- How I want people to treat me
- What I want my loved ones to know
Lifecare Advance Directive (2008):
exhaustive and thorough, tedious to complete, but most effective (so far)
Ways to prepare the dead body right after death:
- Stop leakage: Absorbent pads and put the body in a body bag, inform those transporting body
- If leakage is with mouth and tracheostomy sites, use suction and properly position mouth to prevent leakage - Keep jaw closed:- Support jaw with pillow or rolled towel
- What to do with IV lines: - Keep them capped and left in situ, leave endotracheal tubes in situ as well
T/F
Rabies (lyssavirus) are 100% fatal, results in acute encephalomyelitis
True
Rabies (lyssavirus) are 100% fatal, results in acute encephalomyelitis
T/F
Can achieve a “good death” for rabies with antipsyhogenics like haloperidol
True
haloperidol is good for rabies
T/F
Lesser palliative care need for HIV since ART is providing longer lives but more disease
False
Higher palliative care need since ART is providing longer lives but more disease, pain and medication side effect prevalence vs. children who are still dying early as a result of getting more sick than adults
External vs. internal stigma of HIV
External: avoidance, rejection, moral judgement, victimization, abuse of human rights
Internal: self-exclusion, low self-esteem, fear of disclosure, overcompensation
Results of HIV stigma cause
- Avoiding testing, treatment or disclosure
- Avoiding safer sex/safe infant-feeding behavior
- Reduced immune function
- Inhibits access to counseling
Time from seroconversion from HIV to AIDS:
8-10 years
Average survival after AIDS
18-30 months
Time to experience symptoms after gettin HIV
Most people infected with HIV experience flu-like symptoms within 2-6 weeks after infection
Mass casualty events (2)
- “Big Bang” single incidents (earthquakes, tsunamis, hurricanes, tornadoes, terrorist bombings) -
- “Rising Tide” incidents (extensive exposure to chemicals, biological and nuclear agents, pandemic flu outbreaks)
Goals for Mass Casualty Event Management:
1: saving maximum number of lives
Considerations for MCE:
- People not affected by MCE but need PC are less likely to receive it since resources will be diverted to MCE
- Patients for whom curative treatment would normally be given may receive palliative care instead. They may die
- Health workers who do not normally do palliative care may be tasked to do so
Risk factors for burns especially in the developing world
- Open cooking fires/unsafe stoves
- Flammable houses, kerosene lanterns/stoves
- Alcoholism and smoking
- Child abuse and torture
- Self-harm
- Acid attacks; easy access to chemicals
- Occupations that increase exposure to fire
- Poverty, overcrowding and lack of proper safety measures (unsafe wiring, no smoke alarms/extinguishers, fire codes)
- Placement of young girls in household roles like cooking and care of small children
- Underlying medical conditions (epilepsy, peripheral neuropathy and physical and cognitive disabilities)
