Theme C Flashcards

1
Q

Features of Abortion Act

A

Abortion Act 1967
2 medical professionals (need to sign HSA1)
Pregnancy < 24 weeks

  • continuing the pregnancy is a greater risk than termination and injury to mental or physical health to her or any other children OR
  • prevent grave permanent injury to physical or mental health OR
  • risk life of pregnant woman OR
  • substantial risk if the child is prn would suffer from abnormalities that would causes serious handicap

There is no upper limit on gestation if due to 2,3, or 4

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2
Q

What form is required for abortion?

A

HSA1

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3
Q

When can termination be granted in under 16s

A

Without parental consent if:

  • understand all aspects and implications
  • cannot persuade them to tell parents
  • physical or mental health with suffer if they don’t
  • best interests to receive without parental consent
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4
Q

What should happen before a termination?

A
Confirm pregnancy
Discuss methods and choices available
Consider alternatives
Allow time for decision (but earlier has less complications)
Screen for chlamydia and STIs (positive in 13%)
Discuss future contraception
Check Rh status
Check if requires smear
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5
Q

Describe conscientious objection of abortion

A
Section 4 of Abortion Act
Can refuse
Must provide treatment necessary to save a life
Must explain the objection
Cannot express disapproval
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6
Q

Epidemiology of Down’s syndrome

A

1 in 1500 at 20 years
1 in 100 at 40 years
>1 in 50 at 45 years

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7
Q

Screening methods for Down’s syndrome

A

Serum screening - 10 to 14 weeks
Ultrasound - nuchal translucency - 11 weeks to 14 weeks
Quadruple test - 14 to 20 weeks

Once a test has been performed, the chance of the foetus having Down’s is calculated

If > 1 in 150 then offer diagnostic testing

  • Amniocentesis - 12 to 18 weeks (most common after 15 weeks)
  • Chorionic villus sampling - 11 to 13 weeks
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8
Q

Who provides antenatal care?

A

If uncomplicated - midwife and GP led
Small group of medical professionals

Women should carry their own case notes

10 visits - uncomplicated nulliparous
7 visits - uncomplicated multiparous

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9
Q

What do the outcomes framework monitor in relation to pregnancy?

A
Infant mortality (up to 1 year)
Perinatal mortality (including still births), pregnancy, immediately after birth
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10
Q

Define fertility rate

A

births per 1000 women per year aged 15-44

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11
Q

Define number of conceptions

A

total maternities + legal abortions + admissions for miscarriage + ectopic pregnancy

  • 75% are live or still births
  • 18% legal termination
  • 7% miscarriage or ectopic
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12
Q

Define maternity

A

Any pregnancy that results in birth of live or still born child

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13
Q

Define live birth

A

Complete expulsion of product of concetion from mother, regardless of duration which shows any signs of life
- HR, breathing, umbilical cord pulsation, movement

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14
Q

Define abortion

A

Complete expulsion of foetus showing no signs of life prior to 24 weeks gestation

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15
Q

Triennial report - types of maternal mortality

A

Direct - death from obstetric complications

Indirect - resulting from previous existing disease, aggravated by pregnancy

Fortuitous - incidental but during pregnancy

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16
Q

Define maternal mortality

A

Deaths per number of maternities

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17
Q

Most common causes of maternal mortality

A
Hypertensive disease
PE
Haemorrhage
Amniotic fluid embolus
Early pregnancy
Sepsis
Anaesthesia
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18
Q

Define perinatal mortality

A

Deaths occurring during the first 7 days of life and still births per 1000 births

8 per 1000

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19
Q

Define neonatal mortality

A

Deaths during the first 28 days per 1000 births

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20
Q

Define infant death

A

Death within the first year of life

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21
Q

Causes of infant death

A
Low birth weight
Prematurity <37 weeks
Increased age of maternal mother (over 35, increased still birth)
lethal or severe congenital malformation
Infection
SIDS
Accident/trauma
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22
Q

Reasons for choosing home birth

A
Familiar, relaxing environment
Wear own clothes, take shower, eat, drink, move freely
Don't want medical intervention
Cultrual or religious norms 
Hisotry of fast labour
Lower cost
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23
Q

When is home birth not recommended

A
Diabetes
HTN
Epilepsy
Past C-section
prengnacy complication e.g. pre-eclampsia
Breech or abnormal lie
< 37 weeks or over 41
Multiple pregnahcy
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24
Q

Where can a woman give birth

A

ANY WOMAN CAN CHOOSE ANY BIRTH SETTING

- home, midwifery led, obstetric led

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25
Problems with obstetric led birth
Increase itnerventions, not necessarily better outcomes e.g. more episiotomies and C-section
26
Reasons to transfer home or midwife led to obstetric birth
``` Delay in labour Abnormal foetal HR Request for regional anaesthesia Merconium staining Retained placenta Repair of perineal trauma Neonatal concerns post-partum ```
27
Impact of living with uncertain prognosis
Psychologically difficult Worrying about future may impede ability to enjoy present Hyperawareness of physical changes Acquiring information to learn more (excessively) Increased anxiety Depression Concerns over job, situation or career
28
Referral criteria for heart failure nurses
Over 18 with confirmed diagnosis and one of: Need to be started on ACEi or beta blocker Symptomatic on current meds palliative care needs New diagnosis and needs information Recent hospital admission with exacerbation Struggling with self-management
29
Role of heart failure nurses
Improves care and management provides consistent care, readily accessed - observation and management of side effects- provides understanding of meds - makes them aware of symptom deterioration - provides support - first point of call - encourage lifestyle changes
30
Causes of death in children
1. Injuries and poisoning 2. Malignant disease 3. Neurological disorders 4. Congenital malformations 5. Respiratory disorders 6. Infections 7. Congenital disorders
31
Causes of fatal injuries in children
1. RTA 2. Other 3. Drowning 4. Assault 5. Fire 6. Falls 7. Poisoning
32
Methods of accident prevention
RTAs - correctly fitting car seats, compulsory for under 135cm. Speed bumps. Play areas for children. Pedestrian priority Bike accidents: helmets Falls - stair guards, window safety catches Drowning - fences around water Fire- flame resistant materials. smoke alarms Poisoning - child resistant bottles
33
Examples of big child protection cases
Victoria Climbie - 8 year old girl murdered in 2000 - Post mortem shows 128 separate injuries - Inspired Every Child Matters Campaign meaning organisations should share information Baby P - 17 month old died in 2007 - 50 injuries at death - 35 contacts with healthcare professionals Laming report - better sharing of information required
34
Dealing with drug addicted parents
Assess: substances taken, treatment therapies, withdrawal, abstinence - If inadequate - referral to social care When pregnant - planning meeting within 32 weeks
35
MDT in planning meeting in addicted parents
``` GP Obstetrics Midwife Drug and/or alcohol worker Probation Family workers Parents Children's centre Social worker ```
36
Concerning features in drug addicted parents
Defaulting drug/alcohol service appointments Defaulting appointments for support agencies Significant physical, obstetric or mental health problem Drug use chaotic Homelessness Family network breakdown
37
STI epidemiology
1. Chlamydia 2. Genital warts 3. Non-specific genital infections 4. Gonorrhoea 5. Other 19% ``` Increasing prevalence Most common in 15-24 years Rising syphilis and gonorrhoea Decreasing genital warts Increased in MSM ```
38
Prevention of STIs
- Counselling: safe sex - Comprehensive sex ed - Target at risk populations: sex workers, MSM, IVDU - Barrier contraception - Vaccinations: hep B and HPV Make services free /affordable Population based national plans
39
High risk groups for STIs
``` 15-24 MSM Blacks and ethnic minorities Learning disability Homeless Custodial setting In care ```
40
Opportunities for sexual health promotion
``` Open access to health professionals Screening for chlamydia Target high need communities In school Sexual health clinics During routine consultations During pregnancy ```
41
Child Development Services
- MDT of predominantly heath professionals - Multi agency - co-ordinated service - predominantly pre-school with mod-severe difficulties - can provide support until 19 - maintains register of children with special needs - nominated key worker
42
MDT in special needs
``` Paediatrician Physio OT SALT Clinical psychologist Specialist health visitor Dietician Social worker ```
43
At what ages are vaccinations given?
``` 8 weeks 12 weeks 16 weeks 1 year 3 years 4 months 12-13 years 14 years ```
44
Vaccinations give at 8 weeks
5 in 1 vaccine Men B Meningococcal Rotavirus
45
Vaccinations given at 12 weeks
5 in 1 vaccine | Rotavirus
46
Vaccinations given at 16 weeks
5 in 1 vaccine meningococcal men B
47
Contents of 5 in 1 vaccine
``` Diphtheria Tetanus Polio Pertussis Haemophilus Influenza ```
48
Vaccinations given at 1 year
``` haemophilus influenza Men B Pneumococcal MMR Men C ```
49
Vaccinations given at 3 years 4 months
MMR | 5 in 1 vaccine
50
Vaccinations given at 12-13
Only in females | HPV 16 and 18
51
Vaccinations given at 14 years
Tetanus, diphtheria, polio | Men A, C, W & Y
52
Vaccinations given at 65 years
annual influenza | Pneumococcal
53
Ethics of vaccination
Autonomy and liberty - parental automony, raise child as they see fit Neglect - child should not be exposed to disease or illness or denied medical care Autonomy - mandatory vaccination will infringe on autonomy Utalitarianism - best outcome for the largest number of people. Mandatory vaccinations increase herd immunity. Harm principle - only justification for interfering with liberty is to prevent harm to others. Vaccinations protect the most vulnerable Preventing harm to individuals - vaccines should not put people at risk of harm. if already vulnerable or sick do not give.
54
Reasons against vaccinations
Unnatural mistrust of pharmaceutical companies Fears of unsafe Decreased communicable disease only due to increase hygiene Cannot force them Does not want them - liberty and autonomy.
55
Reasons for and against mandatory vaccinations for health workers
Cannot force vaccinations But can limit the work of someone who has not had the vaccine It has decreased mortality by 40%, decreased work hours lost, cost saving FOR - Duty to not harm others - Herd immunity is an institution - Public trust in health care system may diminish - Consistency between preaching and own actions AGAINST - Autonomy - freedom of choice - Alternatives - increased hygiene levels - Costs of finding non-compliers - better staff education and incentives should increase uptake without mandate
56
Contraindication to vaccinations
Not in severely compromised (BCG, measles, yellow fever) Not in pregnancy (measles, yellow fever, polio) MMR - not in gelatine allergy
57
Chemoprophylaxis for meningococcal infection
Highest risk is first 7 days to household members Without prophylaxis risk is 1 in 300 It is given to household members and partners Aims to decrease risk of invasive disease - eradicates carriers and newly acquired disease Rifampicin and ciprofloxacin Needs to be given within 24 hours Not required if: - school/class members/nursery - work colleagues - friends - kissing on cheek - travelling together
58
Management of meningococcal infection
Cases referred early to CCDC promptly Contact tracing Education Chemoprophylaxis
59
Preventing spread of disease
``` EDUCATION vaccinations isolations when treating hand hygiene PPE during contact with infected Regular cleaning of environment ```
60
Social implications of epilepsy
``` Depression Anxiety Low self esteem Social isolation Decreased sexual relationships Stigma Decreased employment (financial issues) Limits activities - swimming, heights, cycling on roads (if uncontrolled) Poor compliance Altered family dynamic - focus on the ill child (altered sibling relationships) Embarrassment about having a seizure Having to identify the fact you are epileptic Reduced quality of life Worries about becoming a parent - effect of drugs on baby - providing adequate care - inheriting epilepsy Limits alcohol and drug use Restricted driving privileges ```
61
Driving and epilepsy
For a group 1 licence - must be seizure free for 12 months If a single seizure (isolated) after 5 free years then can continue to drive - only works once If you have a seizure - stop driving - inform DVLA - Send licence back voluntarily (can start reapplying 10 months after being seizure free Group 2 licence (HGV) - must be seizrure free for 10 years and not have taken epilepsy medication in this time To apply for a licence - Provide medical report - Details for last seizure - Once you receive your licence it will be medically restricted and valid for 1, 2 or 3 years. Can apply for a long term licence after 5 years seizure free.
62
Driving and Stroke
Cannot drive for 1 month Do not need to inform DVLA immediately but after 1 month (allows time to see lasting stroke effects) Can drive again once a doctor says yes If multiple TIAs must have 3 months TIA free to drive Cannot drive HGV for 1 years
63
When to inform DVLA in neurology
``` Multiple TIAs in short time Worsening condition Epilepsy Brain surgery More than 1 stroke in 3m If doctor expresses concern about ability to drive HGV licence ```
64
Hearing screening in the newborn
Automated Otoacoustic Emissions Test (AOAE) At birth - tests reflections from tympanic membrane, pass or fail Automated Auditory Brainstem Response test (AABR) Detects brain activity from sound, tests cochlea and nerve supply. Done in any failed AOAE or NICU patients If both failed then refer within 4 weeks for audio logical assessment
65
Evidence for treatment in otitis media with effusion
No proven benefit from any treatment or alternative therapy. Hearing aids - NICE recommended if bilateral and hearing loss where surgery no acceptable or contraindicated Pharmacological - non recommended. - No oral or nasal steroids - No antihistamines or decongestants - no antibiotics (Cochrane) Auto-inflation. NICE does not oppose but evidence base is limited. Valsalva manoeuvre Surgery - if >3m and bilateral, if hearing loss >30dB or developmental difficulties - Grommets provide initial improvement but no long term effects, increased infection risk and increased chronic perforation
66
prevention of hearing loss
Decreased noise trauma (ear protection in noisy environments) Avoid ototoxic medications Early treatment of causes Screening of elderly to decrease consequences Noise cancelling headphones rather than increasing volume No objects in ears - cotton buds, tissue
67
Stroke rehabilitation
Starts in hospital Aims to increase QoL Increase independence for physical and psychological well being NICE recommends: - Treat in dedicated stroke in patient unit - MDT - Assess moving and handling, pressure risk, continence, communication, nutritional risk and hydration 1. Psychological function 2. Vision and hearing 3. muscle tone, strength, sensation and balance Physiotherapy, strength training 4. Impairment of body function Including swallowing - SALT, swallowing therapy 5. Activity limitations Long term Set goals
68
Stroke MDT members
``` Neurologist Neurosurgeon Nurses Physiotherapy Occupational therapist Pharmacist SALT Psychologist Social worker Incontinence advice Dietetics Liaison psychiatry Orthoptics Orthotics Podiatry Wheelchair services ```
69
Stroke prevention
``` PRIMARY - Lifestyle: 2 portions of fish/week, 5 fruit and veg a day, 30 minutes of exercise 5 days per week, weight loss, decreased alcohol, smoking cessation - QRISK2 for CV risk - Treat hypertension - Antithrombotic if MI/AF/valve disease - Consider aspirin - Statins if QRISK2 indicates - If AF - CHA2DS2VASc. Females >1 and males >0 anticoagulate ``` SECONDARY - Reinforce lifestyle - Manage hypertension - If AF and non haemorrhagic - anticoagulate - If non-haemorrhagic - clopidogrel - Statins for all - Carotid endarterectomy if carotids >50% - Carotid angioplasty and stents
70
Advantages of the randomised control trial
1. Allows rigorous evaluation of a single variable in a precisely defined patient group 2. Prospective design 3. Uses hypotheticodeductive reasoning 4. Potentially eradicates bias by comparing 2 otherwise identical groups 5. Allow for meta-analysis at a later date
71
Diadvantages of a randomised control trial
1. Expensive and time-consuming - Many are not carried out - Or performed on too few people - Or sponsored by drug companies who dictate research agenda - end points may not reflect outcomes that are important to patients 2. May introduce hidden bias - Imperfect randomisation - Failure to randomise all eligible patients - Failure to blind assessors to randomisation status
72
When is an RCT inappropriate
- Where the study is looking at the prognosis of a disease For this analysis it is best to use a longitudinal survey - Where the study is looking at the validity of a diagnostic or screening test (best to use cross sectional) - Where the study is looking at quality of care in which criteria for success have not been established (better with qualitative)
73
Describe cohort study
2 or more groups of people are selected on the bases of differences of exposure to a particular agent and followed up to see how many get the disease, complication or outcome. Follow up period is usually years. Started on normal people
74
Describe case-control study
Patients with a particular disease or condition are identified and matched with controls. Data is then collected by looking back through medical records or asking them to recall history. Best option for looking at rare disease Cannot be used to determine causality
75
Hierachy of evidence
1. Systematic reviews and meta analysis 2. RCTs with definitive results (CI do not overlap) 3. RCTs with non-definitive results 4. Cohort 5. Case-Control 6. Cross-sectional survey 7. Case report
76
Was the study original, questions to consider?
There is no point testing a scientific hypothesis that someone else has already proved. It needs to add something to the current body of literature - Is this one bigger, continued for longer or more substantial? - Are the methods of this study more rigorous, does it address any specific methodological criticisms of past studies? - Will the numerical results of this study add to meta-analysis of previous studies? - Is the population different? - is the clinical issue of sufficient importance or any doubt requiring further study?
77
Paper appraisal | Is it relevant to your population?
Were those being studied? - More or less ill than your patient - Were they from a different ethnic group - Do they live a different lifestyle - Did they receive more or less attention that your population - is there any comorbidities in your patient, not seen in the study - Number of smokers, alcohol etc.
78
Define palliative care
Approach that improves the quality of life for patients and their families at the end of life. Treatment of pain and problems physical, psychosocial and spiritual
79
Aims of palliative care
- Provides relief from pain and symptom - Affirms life and regards dying as normal process - Intends to neither hasten or postpone death - Integrates psychosocial and spiritual aspects of care - Offers support system to allow patients to live as actively as possible until death - Offers support for the family to cope during illness and bereavement - Uses a teams approach - Enhances quality of life - Is applicable early in course of illness in conjunction with other therapies that can prolong life e.g. chemo and radiotherapy
80
End of Life Strategy
Published by Department of Health in 2008 It identified a number of significant issues affecting dying and death Patients will have - Opportunity to discuss needs and preferences - Have a recorded care plan - Co-ordinated care and support - Rapid service and clinical assessment - high quality care and support - Treated with dignity - Appropriate support for carers and families - Services will be monitored and assess to ensure quality. National Intelligence Network to collect, analyse and publish data - Services to be informed by experience of others: VOICES survey
81
Define good death
- Being treated as an individual with dignity and respect - Being without pain and other symptoms - Being in familiar surroundings - Being in the company of close family and or friends
82
Where do deaths occur?
58% in hospital 18% at home 17% in care homes 4% in hospices
83
Palliative care pathway steps
- Identify people approaching end of life and initiate discussion about preferences for end of life care - Care planning: assess needs and preferences, agree to care plan and review regularly - Co-ordination of care - Delivery of high quality services in all areas - Management of last days of life - Care after death - support for carers during and after illness
84
What is the Gold Standards Framework and what are its aims?
It is recommended by the End of Life Strategy 2008 It is a way of working that has been adopted across the UK with regards to palliative care; - Identify people in need of special care - assess and record their needs - Plan and provide care AIMS - Physical symptoms are reduced - Patients have a choice and control over place of care - Patients feel sense of safety and security and feel supported - Family and carers feel supported, enabled and informed - primary care team work effectively with other health professionals
85
What are the 7 C's of Gold Standards Framework
1. Communication 2. Coordination of care 3. Control of symptoms and ongoing assessment 4. Continuing support 5. Continued learning 6. Carer and family support 7. Care in final days
86
RCT - assessing allocation
Was there random allocation? Is the method of allocation described? How was the randomisation schedule generated? How was a participant allocated? Were the groups balanced? Any differences address and accounted for? If there were any differences - could they be confounders?
87
RCT - assessing blinding?
Consider that blinding is not always possible Has every effort been made to achieve blnding? Does it matter in this study?
88
RCT - were all who entered the trial accounted for in its conclusion?
- If any intervention group participatns were given a control group option of vice versa - If all participatns were followed up in each study group (any loss to follow up) - Analysis through intention to treat? - What additional information would be valuable?
89
RCT - were all participants treated in the same way?
Reviewed at same time periods? If they received the same amount of attention? Any differences? Could this have affected the results?
90
RCT - is it applicable locally?
Are the people in the trial different to your population Does the local setting differ Can the same level of treatment be provided Consider outcomes from point of view of individual, policy maker, professionals, family and wider community - Any benefit, does it outweight any harms or costs COST ANALYSIS Should policy be changed.
91
Define guidelines
A consensus of best practice based on available evidence in health care
92
Features of an effective guideline
- Wide range of clinical and user perspectives - External reviews incorporated - Time limit used
93
Methods of implementing guidelines
``` Computer messages Audio visual aids Electronic publications Educational Outreach visits Local opinion leaders (consultants) Computer Decision Support systems ```
94
Groups that need special precautions with food poisoning
``` Pregnant women Very young Very old People who work with food People who work with immunocompromised (healthcare) ```
95
Common food poisoning causative agents
``` Campylobacter (from milk and poultry) Shigella (salad, veg and dairy) salmonella (eggs, meat, poultry) Clostridia (spores in meat) Listeria (meat, dairy, fish, shellfish) ```
96
Dealing with an outbreak of food poisoning
Identify and isolate the source Identify and treat infected individuals Advse and further treatment and prevention of spread - Hygiene - Off work for 48 hours - Notify HPA - Public health (control of disease act) 1984
97
Common causes of nosocomial diarrhoea
``` Clostridium difficile Norovirus Rotavirus E.coli Klebsiella MRSA ```
98
Factors considered when allocating organs
Tissue type matching (ABO and HLA) Type of organ Location or organ and nearest recipient (ischaemic time)
99
Factors leading to increased transplant rates
Large number of transplant centres High percentage of the population university educated High percentage of Roman Catholics Proactive donor detection programme Economic reimbursement for hospitals High number of RTAs
100
Assessing cost effectiveness of screening
Estimate costs in relation to calculated number of years saved (cost-effectiveness analysis) - Cost of equipment - Cost of additional examination (depends on false + rate) - Prevalence and mortality in the examined population - Compliance rate - Cost of primary therapy - Costs saved by reducing number of cost-intensive therapies for advanced stages - Effect of years gained on GNP, income and taxes
101
Diabetes MDT
``` Diabetes specialist nurse Podiatrist Dietician Doctor Endocrinologist Nephrologist Ophthalmologist Cardiologist Neurologist ```
102
Medical conditions more common in obese patients
``` Arthritis T2DM CVD Cancer End stage renal disease Chronic venous insufficiency Gout Sleep apnoea Stroke DVT/PE HTN Urinary stress incontinence Surgical complications ```
103
SMART targets
``` Specific Measureable Achievable Realistic Time bound ```
104
National Obesity Forum
Established to raise awareness of the growing impact of obesity on our patients and NHS - Create recognition of obesity as a serious medical problem - Produce education on obesity management - Provide guidelines for obesity management in primary care - Provide a network for support and in information resource - Convince the government to give obesity a high priority - Highlight health inequalities of obesity
105
National Service Framework for Mental Health
Set of policies created to define standards of care for major medical issues - Help drive up equality and remove the wide variations in provision of care - Set national standards and define service models - Put in place programmes and support local delivery of services - Establish milestones and performance indictors to measure.
106
NICE recommendations for fertility treatment
Women under 40 unable to conceive after 2 years of regular unprotected intercourse get 3 cycles of IVF Women aged 40-42 are offered 1 cycle but only if they have not had IVF in the past and they DO NOT have low ovarian reserve Ovarian stimulation can be given in unexplained fertility Intrauterine insemination can be used if endometriosis, mild male infertility or a physical or psychological problem with having sex
107
Risks associated with fertility treatment
Multiple pregnancy Ectopic pregnancy ovarian Hyperstimulation syndrome
108
Complaints in the NHS
2 stage process - Ask GP, hospital or trust for a copy of complaints procedure - Raise the matter verbally or written with the practioner or to NHS England or to local BBG (local resolution) Most are sorted at this stage If still unhappy can refer to Parliamentary and Health Service Ombudsman who is independent of the NHS and government
109
Common complaints in NHS
1. Safety of clinical practice 2. Poor or insufficient information 3. Ineffective clinical practice 4. Poor handling of complaints 5. Discharge and co-ordination of care 6. Lack of dignity and respect 7. Poor attitudes of staff 8. Failure to follow consent procedures 9. Poor environment including poor hygiene 10. Lack of access to personal clinical records
110
Problems in handling of complaints
Failure to acknowledge validity of complaint Failure to apologist Response do not explain what has been done to prevent recurrence Response contain medical or technical jargon Failure to involve staff directly concerned in the complaint in the investigation
111
High risk groups for STIs
``` Young Black/ethnic minority Gay/bisexual IVDU HIV positive Sex workers Prisoners ```
112
Down's screening
Combined test between 10 and 14 weeks - Blood test: beta hcg and PAPP-A - Nuchal scanning Quadruple test after 14 weeks - beta hcg - AFP - Inhibin A - Unconjugated oestradiol Raised beta hcg and inhibin A in Down's Low UE3, AFP and PAPP-A If result shows risk > 1/150 then amniocentesis or chorionic villus sampling is offered
113
Current antenatal and neonatal screening
``` Anencephaly Spina bifida Cleft palate/lip Diaphragm hernia Gastrroschisis Exomphalos Cardia and renal complication Edward's Patau's ``` Sickle cell and thalassaemia Hep B, HIV, rubella, syphilis in pregnancy Newborn blood spot - CF, PKU, hypothyroidism, MCAD Newborn hearing New born and 6 week baby check
114
Contraindications to live vaccines
Receiving cancer treatment or finished in the last 6 months Taking immunosuppressive drugs Bone marrow transplant in last 6 months Taking high dose steroids Evidence of immune impairment HIV positive
115
Vaccinations given at 2 months
Rota virus 5 in 1 Pneumococcus
116
Vaccinations given at 3 months
Rotavirus 5 in 1 Men C
117
Vaccinations given at 4 months
5 in 1 | Pneumococcal
118
Vaccinations given at 1 year
Hib Men C MMR Pneumococcal
119
Every Child Matters Key Outcomes
``` Healthy - physical/mental/lifestyle Safe - from harm and neglect Enjoy & achieve - most out of life Contribute - to society and community Economic wellbeing - full potential ```
120
Purpose of MDTs for child safety
Children get the help they need when they need it Professionals take timely action to protect children Professional ensure children and listened to and respected Agencies and professionals work together to assess needs and risk and develop effective plans Professionals are competent and confident Agencies work with members of the community
121
Psychosocial issues regarding back pain
``` Constant discomfort from the pain Loss of income Depression Loss of independence Feeling of guilt/like a fraud Side effects from medications Relationship issues Decreased social/ leisure activities Inability to care for the family Decreased libido ```
122
Epidemiology of falls
30% over 65 suffer from falls Incidence is increasing with ageing population In residential care fall are 3x higher ``` RFs Parkinsons Stroke Arthritis Joint disease Muscle weakness/myopathy Incontinence Gait abnormality Incontinence Postural hypotension Low BMI ``` ``` Poor lighting Steep stairs Rugs/ loose carpet Slippery floors Cluttered areas Poorly fitting footwear ``` Polypharmacy Sedatives Antihypertensives Dementia Visual impairment Diabetic neuropathy Hearing impairment
123
Consequences of falls
Fractures NOF Head/ eye injuries Wrist # Spinal # Long lie - hypothermia - pressure sores - rhabdomylysis - dehydration Loss of confidence, immobility, isolation, depression, decreased independence, long term care
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Methods for preventing falls
``` Homes based strength and balance training Daily cleaning of spectacles Regular vision checks Staff monitoring in nursing homes Home safety assessment and modifications Podiatry Walking aids ```
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Benefits of blind registration
``` Blue badge parking permit Leisure centre consessions bus and rail ticken concessions TV licence concessions Career and employment advice Disability Living Allowance ```
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Blind registration
Can only occur if recommended by consultant ophthalmologist Registration is voluntary, only 30% register (stigma, unaware of system)
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Principles of Quality Standards for Older People
1. Remove age discrimination 2. person centred care 3. Integrate services to promote faster recovery 4. Specialist services in hospital 5. Reduce incidence of stroke 6. Reduce incidence of falls 7. Promote good mental health 9. Extend healthy life expectancy
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NICE technology appraisal
Assess the evidence base and clinical and cost effectiveness of new and existing healthcare technologies with a view to providing single, authoritative source of advice on interventions and procedure Technology appraisal is mandatory to gain funding Technologies that can be appraised are: - Drugs - Diagnostic tests - Clinical devices - Surgical and clinical procedures - Health promotion interventions
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Technology appraisal process
1. Topic selection - through consultation with industry and NHS and patient groups 2. Data submission - industry is required to submit all trial data according to NICE criteria 3. Data review - NICE appraisal committee allocates data to an academic centre to report on clinical and cost effectiveness 4. Call for contributions = from interested parties including stakeholders (manufactures, Royal colleges, patients, carers) 5. Funding. If mandatory CCGs must fund the service if it is required
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Quality standard criteria for dementia
1. Care from specialist dementia staff 2. memory assessment 3. written information 4. personalised care plan 5. opportunity to discuss advanced decisions 6. assessment and management of non-cognitive symptoms 7. Special dementia liaison services 8. Assessment of palliative care 9. Address carers emotional, psychological and social needs 10. Respite services
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Quality standard for suspected stroke patients
- Screened with validated tool - Receive brain imaging within hour - Admitted directly to acute stroke unit, assess for thrombolysis - Swallowing assessment before feeding - Ongoing rehabilitation - Minimum 45 minutes of active therapy per day - Treatment plan for incontinence - Scree for cognitive and mood disturbance within 6 weeks - Specialist stroke rehabilitation services after discharge - Carers given contacts and information
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Criminal Transmission of HIB
Intentional - deliberate transmission with aim to cause harm Reckless - not deliberate but careless Accidental - unaware of condom failure Hard to prove HIV is not a notifiable disease Doctor has a duty of care to the patient, but also to protect those that might be at harm Doctor has a duty of confidentiality to the patient Doctors may breech this if they are protecting another from serious harm Ask advice from medical defence union or GU consultant
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Why monitor adverse events?
Common - important consequences Up to 50% are preventable Can learn from adverse events Can reduce in future and improve care
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National patient safety agency
It is the body responsible for handling adverse events and adverse events should be reported to them. Example - Yellow card reporting for drug side effects
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Never events
Wrong site surgery Wrong implant/prosthesis Retained foreign object post-op Selection of a high potassium solution Wrong route of administration Overdose of insulin due to abbreviations or incorrect device Overdose of methotrexate for non-cancer treatment Mis-selection of high strength midazolam during conscious sedation Failure to install functional collapsible shower or curtain rails Falls form poorly restricted windows Check or neck entrapment in bed rails Transfusion of ABO incompatible blood Mis placed NG tube (that is then used) Scalding of patients
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Criteria for consent
For consent to be valid it must be: - Voluntary - Informed - patient must have capacity
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When is consent not required?
Additional procedures - if it is too dangerous to wake the patient to get consent (surgery) Emergency treatment mental health condition under mental health act 1983 Risk to public health (Public Health (Control of Diseases) Act 1984) Severely ill and living in unhygienic conditions (National assistance act 1948) - taken to a place of care with or without consent
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Consent and children
Over 16 - make own decisions Under 16s can consent to treatment if they are Gillick competent. If a child refuses treatment then their decision can be overruled by the Parents of Court of protection If a parent refused to consent for a treatment for their child that prevents injury/death this can be overruled by the courts Only one parent needs to consent Consent not required in emergency
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4 ethical principles
Justice Autonomy Non-maleficence Beneficence
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Situations where can break confidentiality
DVLA if patient will not inform themselves Required by law Gunshot and knife wounds reported to police Communicable diseases Risk to child's safety General principles - Protect children - protect public from acts of terrorism - Under Drug Trafficking Act 1986 - Prevent or detect a crime - In life threatening situations - Protect service provider e.g. violent patient
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Define euthanasia
Deliberately ending a person's life to relieve suffering - Active - Passive (withdrawal of treatment) - Voluntary - asking for help - Non-voluntary - unable to give consent e.g. coma
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Define assisted suicide
Act of deliberately assisting or encouraging another person to commit suicide
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Arguments for euthanasia
Ethics - freedom of choice (AUTONOMY) - DNACPR is a form of passive euthanasia - Palliative sedation - likely shortening lifespan Beneficence = acting in the patient's best interests
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Doctrine Double Effect
An act is allowed if it brings about a good consequence that can only be achieved at risk of a harmful side effect
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Arguments against euthanasia
Religious - only god has that right Slippery slope - Ill people may feel pressure to accept euthanasia to not be a burden - Discourages research into palliative care - Misdiagnosis or prognosis could lead to unnecessary euthanasia Violates ethical code of doctors - do no harm Non-maleficence Lack of compassion Alternatives are available - Palliative care and mental health care - Can still have painless death with dignity
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Reasons for abortion
AUTONOMY - women have the right to decide what happens to their body JUSTICE - right to abortion is vital for women to achieve full potential e.g. teen pregnancy BENEFICIENCE - force women to use illegal and unsafe abortionists JUSTICE and BENEFICIENCE - avoid emotional harm of bearing a child from rape NON-MALIFICEINCE - foetus is immature entity and would not survive outside of uterus BENEFICIENCE - undesired pregnancy can decrease quality of life and psychological harm for mother
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Reasons against abortion
JUSTICE - all forms of human life have the right to life NON-MALIFIENCE - deliberate ending of another's life is no different to murder NON-MALIFEINCE - medical complications later in life JUSTICE - many couples are looking to adopt and abortion denies them this opportunity
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Research ethic principles
Nuremburg code for research ethics principles - Voluntary consent from all involved - Should yield results beneficial to society that cannot be acquired by other means - Based on animal experimentation and knowledge of natural history of disease - Avoid all unnecessary physical and mental suffering - Should not be performed if there is a prior reason to believe the intervention is harmful - Risk should not exceed humanitarian importance - Preparation and facilities should be provided to protect subjects from injury, disability or death - Conducted by scientifically qualified people - Can leave whenever they wish - Scientist in charge should be prepared to end experiment if harm comes to subjects
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When to report under age sexual activity
Child under 13 Belief that they are abused or exploited Lacks capacity
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Define confidence interval
Range of values that is 95% likely to contain the true value Describes the level of uncertainty in the sample.
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What information is required to interpret a confidence interval?
Confidence level e.g. 95% Statistic Margin or error Sample statistic +/- margin or error
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Define p value
Likelihood that the observed result is due to change | P > 0.05 is not statistically significant
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What results in a change to the size of the confidence interval
Variation in sample data Chosen % interval Sample size
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Define power
The probability that it will reject a false null hypothesis It is inversely related to the probability of making a type 2 error It is the likelihood that a study will detect an effect when there is an effect to be detected. It is affected by the size of the effect and the size of the sample used to detect it.
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Purpose of blinding
Eliminates - Investigator bias - Evaluation bias - Hawthorne effect - participant may exaggerate the effects
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Types of blinding
Single = only the participant is unaware about which treatment they are receiving Double = both the participant and the investigator are unaware about the intervention This eliminates observer bias Triple = in addition, the evaluator is not aware of the process
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Define null hypothesis
No difference | No effect
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Define randomisation
The allocation of treatments to patients using a random process - Allocation should be unbiased - Treatment groups should be balanced This is so there is a fair test of efficacy
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Types of randomisation
Restricted randomisation Block randomisation Minimisation Stratification
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Define restricted randomisation
Number of patients in each group are chosen in advance
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Define block randomisation
This ensures similar numbers of paitents are in each group. For each block, half to treatment, half to placebo Block size can be changed and it can be stratified into subgroups
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Define stratified randomisation
Stratification gives an equal distribution of risk factors between groups in an attempt to reduce confounding.
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Why randomise?
Ensures investigator cannot influence who is in which group In the long run the groups and comparable in known and unknown factors Any observed effect is due to treatments.
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Define selection bias
This occurs if the likelihood of enrolling a certain patient is influenced by knowing which treatment they might receive
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Define responder bias
Knowledge of which group a person is in can influence response. Based on placebo effect.
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Common confounding factors
Age Sex Demographic characteristics
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Intention to treat analysis
Once a patient has been randomised they must be analysed in their allocated group regardless of whether they followed the protocol correctly
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Per protocol analysis
Reports who actually got which treatment and analyses as such Does not reflect real life
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What is a confounder
They are factors that influence treatment and outcome measures and include demographic characteristics, prognostic factors and other characteristics that may influence someone's likelihood of participating or withdrawing from the trial
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Define internal validiyu
Accuracy how well the study was conducted taking into account confounders and removing bias
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Define external validity
Generalisability | How well the study can be applied to different scenarios
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Type 1 error
Null hypothesis is rejected when it is true (result of trial wrongly shows a difference( False positive Not affected by sample size Increased by increased number of end points Probability of type 1 error = alpha
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Type 2 error
Null hypothesis is ACCEPTED when it is false Result of trial fails to show the true difference False negative Decreased by a smaller sample size Probability of type 2 error = beta
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Define absolute risk
Risk of disease among the population being studied
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Define relative risk
Risk if disease among exposed compared to that of non-exposed
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Define risk ratio
Probability of disease in the at risk group / risk of not at risk group
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Define odds ratio
It is a the measure of an association between exposure and outcome. It represents the odds that an outcome will occur given a particular exposure
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When is an odds ratio used
In case control studies Mostly Can sometimes be used in cross-sectional and cohort studies
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What does an odds ratio >1, <1 and equal to 1 mean
OR = 1. Exposure does not affect odds of outcome OR > 1. Exposure is associated with higher odds of outcome OR < 1 exposure is associated with lower odds of outcome
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Calculating odds ratio
ad/bc ``` a = positive outcome, positive exposure b = negative outcome, positive exposure c = positive outcome, negative exposure d = negative outcome, negative exposure ```
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Absolute risk reduction
risk in exposed - risk in unexposed
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Number needed to treat
1/ absolute risk reduction Number of patients needed to be treated to produce 1 improved outcome Round up for benefit Round down for harm.