Y2

Question 1

Why is knowing about decision making important?

Answer 1

• Doctors constantly make decisions.
• Their decisions have effects on patients, their families, society.
• An understanding of decision making, the role of evidence, can help improve medical practice.

Question 2

What process do doctors use when making diagnoses?

Answer 2

Hypothetico-deductive reasoning

Question 3

What must an evidence-based decision include?

Answer 3

• Clinical expertise
• Evidence from research
• Patient preferences
• Available resources

Question 4

What type of decision is a cohort study appropriate for?

Answer 4

 Looks at a population and assesses their risk factors and evaluates who gets disease over time
 Observational study - Can be retrospective or prospective

• Assessing the effect of a risk factor/exposure

Question 5

What type of decision are case-control studies appropriate for?

Answer 5

 Looks at a group of individuals with a disease and matches them to those with similar demographics

 Observational study - Looks back and compares risk factors

Question 6

What type of decision are RCT’s appropriate for?

Answer 6

• Treatment interventions

- Benefit and harm; cost-effectiveness

Question 7

What type of decision are qualitative studies appropriate for?

Answer 7

• Patient perspective

- Practitioner perspective

Question 8

What type of decision are diagnostic and screening studies appropriate for?

Answer 8

Identification

Question 9

What type of decision are systematic reviews appropriate for?

Answer 9

Summary of evidence for a specific question

 Looks at all available evidence and combines the results to determine what the evidence says overall (meta-analysis)

 Highest level of evidence

Question 10

What is evidence based medicine?

Answer 10

Process for identifying and using most up-to-date, relevant evidence to inform decisions for individual patient problems.

Question 11

Why do we need evidence-based medicine?

Answer 11

• Increasing medical knowledge
• Limited time to read
• Inadequacy of traditional sources of information (out of date textbooks)
• Disparity between diagnostic skills/clinical judgement and up to date knowledge/clinical performance

Question 12

What is the process of EDM?

Answer 12

• Converting the need for information into an answerable question;
• Identifying the best evidence to answer that question;
• Critically appraising the evidence for its validity, impact and applicability;
• Integrating the critical appraisal with clinical expertise and the patient’s unique circumstances;
• Evaluating our effectiveness and efficiency in carrying out steps 1-4 and seeking ways to improve them.

Question 13

Types of questions?

Difference between the two?

Answer 13

• Background questions
• Foreground questions
• Background questions are for general knowledge about a disorder, they contain a question root and the disorder.
• Foreground questions are for specific knowledge about managing patients with a disorder. They contain 4 (sometimes 3) essential components. (PICO)

Question 14

What is PICO?

Answer 14

• Population
• Intervention
• Comparison
• Outcome

E.g. In younger women with breast cancer, is mastectomy with chemo more effective than mastectomy alone, in reducing the risk of cancer recurrence?

Question 15

After deciding PICO, what is next?

Answer 15

• Identify the best evidence by carrying out a structured search.
• Appraise the identified evidence.
• Integrate the evidence into decision making for the individual patient.

Question 16

What is the chain of infection?

Answer 16

• Infectious agent
• Host
• Portal of entry
• Mode of transmission
• Reservoir/environment

^ all linked together

Question 17

Characteristics of an infectious agent/pathogen?

Answer 17

• Ability to reproduce
• Survival (inc. environmental)
• Ability to spread
• Infectivity (ability to cause infection; also colonisation without infection)
• Pathogenicity (severity of the illness)

Question 18

What is the reservoir/environment?

Answer 18

• ‘Exposures’- don’t forget relationship to lifestyle as a ‘host’ issue
• Animals as reservoirs
• Other humans
• Water systems e.g. Legionnaire’s disease in air conditioning systems
• Environmental contamination

Question 19

What is the mode of transmission of an infectious agent?

Answer 19

Respiratory spread

• Droplet (3 feet)
• Airborne (suspended particles)
• Plus aerosolization of water

Ingestion

• Direct consumption
• Hand-to-mouth
  
  • Contamination from people
  • Contamination from environment

Blood borne

Sexual contact

Question 20

What are the portals of entry of an infectious agent?

Answer 20

• Mouth
• Nose
• Ear
• Genital tract
• Skin (breakdown of barrier)

Question 21

What are host factors in the transmission of an infectious agent?

Answer 21

• Chronic illness
• Nutrition
• Age (very young, very old)
• Immunity (immune condition; chemo; transplant etc)
• Lifestyle factors (drugs; alcohol; sex; occupation; poverty; leisure activities)

Question 22

Define outbreak in the context of infection.

Answer 22

An outbreak of infection is: sudden increase in disease occurrences in a particular time and place

• Some diseases need a sudden increase in a defined area over a short time period
• Some diseases need 2 or more connected cases between space and time
• Some diseases only need 1 case to be considered an outbreak e.g. smallpox

Question 23

Define pandemic.

Answer 23

An epidemic occurring over a very wide area.

E.g. crossing international boundaries.

Question 24

Define surveillance.

Answer 24

• Systemic collection, collation and analysis of data
• Dissemination of the results so appropriate control measures can be taken
• POINT OF CONTROL

Question 25

Define epidemic.

Answer 25

- Occurrence of an illness/ health-related behaviour/ health related event clearly in excess than normal expectancy in a community or region. - Thresholds define what constitutes them. - Thresholds decided using info from GPs.

Question 26

List the common problems of surveilling outbreaks.

Answer 26

- Can look/present similar to other diseases - Diagnosed as something else/ may not be tested - Not everyone notifies/ Doctors may forget - Lab tests may not be routinely available/may take time to come back/ not very good - Some people may not want to disclose illness - Potential recall bias in Enhanced Surveillance Questionnaires (ESQ) - Syndromic surveillance

Question 27

List common healthcare associated infections (HCAI).

Answer 27

- Norovirus (viral gastroenteritis) - Carbapenemase producing organisms (CPO) - antibiotic resistance - MERs-CoV - novel or emerging infections where hospital is amplification point

Question 28

What can increase risk of having healthcare associated infections HCAI?

Answer 28

- Underlying diseases - Extremes of age - Breach of defence mechanisms e.g. IV drip in patient will breach skin - Exposure to infection - Hospital pathogens – more resistant - Antibiotics resistance

Question 29

How much do healthcare associated infections HCAI cost per year?

Answer 29

Approx £1bn

Question 30

Different control measures of healthcare associated infections HCAI?

Answer 30

- Hospital environmental hygiene (including isolation of cases) - Hand hygiene- MOST EFFECTIVE - Use of PPE (gloves, face mask, googles) - Safe use and disposal of sharps; and - Principles of ASEPSIS! - AB prescribing policy

Question 31

What is the infection control programme?

Answer 31

- Surveillance of HAIs – MRSA and MSSA bacteraemia and C.difficile infections - Detection, investigation and control of outbreaks - Policies and procedures to prevent and control infection - Dissemination and implementation of national policies - Education and training - Monitoring clinical practice

Question 32

What is global health?

Answer 32

 Health of the global population  Improving health and achieving equality in health for all people worldwide  Emphasises transnational health issues, determinants and solutions

Question 33

What is the motivation for global health?

Answer 33

- Increased awareness of global health disparities. | - Enthusiasm to make a difference across international boundaries.

Question 34

What is international health defined by?

Answer 34

- Geography (poor nations) - Problems (infections, water, sanitation) - Instruments (infection control, Aid, knowledge, medical resources) - A recipient and donor relationship

Question 35

What is public health concerned with?

Answer 35

- Prevention - Equity - Population-based approaches - Scientifically validated technical approaches

Question 36

What is the '90/10 gap' (commission on health research for development - 1990)?

Answer 36

- 90% resources only treat 10% population - 90% of the world only gets 10% resources Less than 10% of worldwide resources devoted to health research were put towards health in developing countries, where over 90% of all preventable deaths worldwide occurred.

Question 37

List examples of global issues.

Answer 37

- Global warming - Development, poverty and inequality - Food and water security - Wars and security threats - Migration

Question 38

What are the relationship/actors/motivation and main instruments for development aid?

Answer 38

- Dependence - Donors and recipients - Charity; self interest - Discretionary allocations

Question 39

What are major functions of global health?

Answer 39

- To provide health-related public goods, i.e. research, standards, and guidelines. - To manage cross-national externalities through epidemiological surveillance, information sharing, and coordination. - To mobilise global solidarity for populations facing deprivation and disasters. - To convene stakeholders to reach consensus on key issues, setting priorities, negotiating rules, facilitating mutual accountability, and advocating for health in other policy-making arenas.

Question 40

What is the goal of vaccinations?

Answer 40

- To reduce mortality and morbidity from vaccine-preventable infections - Using vaccination strategy adapted to the epidemiology

Question 41

What is the strategic aim of vaccinations?

Answer 41

- Selective protection of the vulnerable - Elimination – through herd immunity - Eradication

Question 42

What is the programmatic aim for vaccinations?

Answer 42

- Prevent deaths - Prevent infection - Prevent transmission (secondary cases) - Prevent clinical cases - Prevent cases in a certain age group

Question 43

What is eradication of an infectious agent?

Answer 43

- Where no other reservoirs of the infection exist in animals or the environment. - E.g. smallpox or polio

Question 44

What is the crucial factor determining the spread of infection?

Answer 44

The number of secondary cases caused by each infectious person

Question 45

What is an example of a conjugated vaccine and when was it introduced?

Answer 45

- HiB - Meningitis - Pneumonia - 1999

Question 46

What is the R0 proportionate to?

Answer 46

- The length of time the case remains - Number of contacts a case has with susceptible hosts per unit time - The chance of transmitting the infection during an encounter with a susceptible host

Question 47

What is the basic reproduction number (R0)?

Answer 47

- Average no. of secondary infections produced by a typical infective agent in a totally susceptible population - Doesn’t fluctuate in the short term - Not affected by vaccination (so it's not realistic) - Property of the infectious agent

Question 48

When can the R0 differ?

Answer 48

Different infections in the same population - UK, R0 (measles) > R0 (rubella). Same infection in different populations - Measles, R0 (Nigeria) > R0 (UK) - Reflects population characteristics such as density.

Question 49

What is the effective reproductive number (R)?

Answer 49

R is the actual average number of secondary cases per primary case observed in a population Usually smaller than R0 Reflects impact of control measures - Early stage, R=R0

Question 50

What is the effective reproduction number (R)?

Answer 50

Average number of secondary infections produced by a typical infective agent in a homogeneously mixing population, where s is the proportion susceptible R = Ro x s S = fraction of the host population which is susceptible)

Question 51

What makes a population susceptible?

Answer 51

Any person not immune to a particular pathogen Because: - Never encountered the infection/vaccine before - Unable to mount an immune response e.g immunocompromised/suppressed - Vaccine is contraindicated

Question 52

Using the equation R=Ro x s, with Ro being 10, how many people will an infected person infect, if s is 20%, 10%, 5%?

Answer 52

S = 20% - R = 10 x 20% - R = 10 x 0.2 - R = 2 people S = 10% - R = 10 x 10% - R = 10 x 0.1 - R = 1 person S = 5% - R= 10 x 5% - R= 10 x 0.05 - R= 0.5 of a person…

Question 53

How do mass vaccination programs impact the disease?

Answer 53

- Reduce size of susceptible population - Reduce number of cases - Reduce risk of infection in population - Reduce contact of susceptibles to cases - Lengthening of epidemic cycle - Increase mean age of infection

Question 54

What is the epidemic threshold?

Answer 54

- R= 1 - If R > 1, number of cases increases - If R > 2, number of cases increases exponentially - If R < 1, number of cases decreases - To achieve elimination, must maintain R < 1

Question 55

How do you work out critical proportion susceptible (s*)?

Answer 55

``` Threshold at R = 1 defines the s* Therefore - R = Ro x s - 1 = Ro x s - S* = 1/Ro ```

Question 56

How do you work out the critical vaccination coverage?

Answer 56

H = herd immunity threshold H = 1 – S* Measles in the UK: H = 95% (s* < 5%) Once > 5%, thn R > 1

Question 57

What does the critical vaccination coverage depend on?

Answer 57

Vaccine efficacy

Question 58

What is herd immunity?

Answer 58

- Level of immunity in the population which protects the whole population - Only applies to diseases passed from person to person - Indirect protection to unvaccinated as well as direct effect to vaccinated

Question 59

What do you need to consider when choosing the best strategy to implement vaccination programmes?

Answer 59

- Risk of exposure - Risk of disease and complications - Susceptibility - Vaccine features: safety, side-effects, efficacy - Acceptability/ timing issues

Question 60

What is the role of the WHO in international vaccination strategy and policy?

Answer 60

Makes recommendations for countries on vaccination policy Supports less able countries with vaccination strategy implementation Works through the International Health Regulations - “to ensure the maximum security against the international spread of disease with a minimum interference with world traffic”

Question 61

Give some examples of international immunisation programmes.

Answer 61

- Expanded programme on Immunisation (EPI) - Global Polio Eradication Initiative (GPEI) - Global Alliance for Vaccines and Immunisation (GAVI)

Question 62

Why is international collaboration necessary for imunisations?

Answer 62

- Inequity in access to immunisation services: - More evident in some of the least-developed countries - Low political commitment and under investment in some countries may not keep pace with population growth - Higher costs of service delivery - R+D may not address the needs of the world’s poorest children - Lack of commercial incentives for manufacturers to develop new vaccines e.g. HIV/Aids, TB and malaria - Some countries may not be able to guarantee vaccine quality and safety so: greater risk of poor immunisation practices + children’s lives being put at unnecessary risk

Question 63

When was the vaccination law introduced in Britain? Did it work?

Answer 63

1889 No, progressive decline in compliance The British don’t like being told what to do

Question 64

Name 3 descriptive methods for collecting research population data?

Answer 64

- Case report - Case series - Survey

Question 65

Name explanatory (analytical) methods for collecting population research data?

Answer 65

Can be observational or experimental. Observational: - Cross-sectional - Cohort - Case-control Experimental: - Laboratory - Trials (RCT)

Question 66

Which type of studies seek to make comparisons?

Answer 66

Analytical (explanatory) - They compare experimental vs. observational - Inference about exposures and outcomes.

Question 67

Describe case studies (descriptive).

Answer 67

``` – Report on 1 or a few cases – Usually a rare condition – Limited to ‘real world’ conditions – Any conclusions about cause or outcome are author’s conjecture ```

Question 68

Describe case series (descriptive).

Answer 68

– Describe (often unusual) clinical course of condition of interest – Might provide information about prognosis if cases are representative of all cases – Again, no direct data but features might help build hypotheses

Question 69

What is the difference between prospective vs. retrospective observational studies?

Answer 69

Has outcome occurred before study starts? • yes = retrospective • no = prospective Advantage of prospective • data quality • better able to study incidence

Question 70

List the advantages and disadvantages of experimental studies.

Answer 70

– Investigator can allocate study subjects Advantages • stronger evidence of causation • control of confounders through randomisation Disadvantages • limited range of hypotheses • may not be “do-able”

Question 71

List the advantages of observational studies.

Answer 71

No allocation of study subjects • Do not confuse random sampling with random allocation! • Observation in a real-world setting ``` Advantage • Complex web of causation might not be otherwise reproducible – practically – ethically – economically ```

Question 72

What are observational studies classified by?

Answer 72

Subject selection: – Cross-sectional studies – Cohort studies – Case-control studies

Question 73

What are the limitations of cross-sectional studies?

Answer 73

– Only suitable for chronic conditions occurring at a moderate level in the population – Only quantifies prevalence of exposure and outcome • May over-represent factors affecting incidence and duration • Can confuse protective risk factors – Reverse-causation • Best for time-invariant exposures (sex, breed, housing) • Can confuse procedures implemented in response to disease

Question 74

What are the pros and cons of cross-sectional studies?

Answer 74

``` Pros – Representative of population – Potentially efficient – Low cost – Rapid ``` Cons – Must verify that risk factor came before the disease

Question 75

Describe cross-sectional studies.

Answer 75

Random sample of subjects selected from population. - Try to represent population in sample. Simultaneously classify according to: - Disease status (or outcome) - Study factor or risk factor Snapshot.

Question 76

Describe cohort studies.

Answer 76

Identify subjects: - With exposure - Without exposure Follow the groups through time to determine if disease develops. Usually prospective.

Question 77

List pros and cons of cohort studies.

Answer 77

Pros: – Less susceptible to bias compared to case-control – More control over quality of data – No confusion on time order of exposure and disease – Good for rare risk factors – Can assess multiple risk factors at once ``` Cons: – Expensive – Time-consuming – Potential losses to follow-up – Only works for diseases common in a population ```

Question 78

Which observational study is usually retrospective and which is usually prospective?

Answer 78

Case-control = retrospective Cohort = prospective

Question 79

Describe case-control studies.

Answer 79

– Identify subjects • with disease • without disease – Compare histories of risk factor (exposure) • Usually retrospective

Question 80

When is case-control studies used?

Answer 80

Rare diseases | Relatively quick and inexpensive if quality data is accessible.

Question 81

List pros and cons of case-control studies.

Answer 81

``` • Pros: – Rare diseases – Potentially efficient – Low cost – Potential for rapid completion ``` • Cons: – Highly susceptible to bias related to selection of controls

Question 82

What is the WHO recommended herd immunity threshold for mumps?

Answer 82

90% coverage

Question 83

Individual rights compared to community health in regards to vaccination?

Answer 83

Individual - Protection by ‘herd immunity’ might be safest option as it avoids risk of vaccine Community - Avoidance of vaccine by lots of people will reduce coverage and diminish herd immunity Basically get vaccinated or you mess up the whole system

Question 84

What is bad news?

Answer 84

Any news that drastically and negatively alter’s the patient’s or their relatives view of his or her future Bad if results in “cognitive, behavioural or emotional deficit in the person receiving the news that persists for some time after the news is received

Question 85

How can bad news be interpreted in psycho-social context?

Answer 85

Social life - Adolescent dx with diabetes can’t drink Employment - Brain surgeon develop tremor due to Parkinson’s, no longer able to work Financial - Self-employed, take time off work, lose money, clients etc Social - Father with chest pain needing to be admitted, may miss daughter’s wedding, not just affecting him but whole family

Question 86

What distancing strategies do clinicians use?

Answer 86

- Avoidance - Normalization - Premature reassurance - False reassurance - Switching - Jollying along

Question 87

What may clinicians worry about when breaking bad news?

Answer 87

- Uncertainty about the patient's expectations - Fear of destroying the patient's hope. - Fear of their own inadequacy in the face of uncontrollable disease. - Not feeling prepared to manage the patients anticipated emotional reactions. - Embarrassment at having previously painted too optimistic a picture for the patient.

Question 88

What 2 mnemonics are there to break bad news?

Answer 88

ABCDE | SPIKES

Question 89

What is the ABCDE mnemonic?

Answer 89

- Advance preparation - Build a therapeutic environment/relationship - Communicate well - Deal with patient and family reactions - Encourage and validate emotions

Question 90

What is the SPIKES mnemonic?

Answer 90

Setting up - Where, with whom, to whom? Perception - What have you been told? Invitation - What do you want to know? Knowledge - How much do you want to know? Emotions - I am sorry/ silence/ validate/ encourage Strategy and summary - Follow up plan

Question 91

What responses to bad news might a patient have?

Answer 91

Basically grief response (can be short or long) - Anger - Denial - Fluctuating mood - Preoccupation w/ situation - Agitation/restlessness - Vegetative signs/symptoms/depression

Question 92

Define incidence of cancer and incidence rate.

Answer 92

Number of new cases of cancer that occur during a specified time in a defined population Incidence rate = number of new cases of disease in a period/ number initially free of disease

Question 93

Define prevalence.

Answer 93

- Burden of disease in a population - All ongoing cases of disease - Prevalence = number of people with disease at any point in time / total population

Question 94

What is important to consider in cancer epidemiology and why?

Answer 94

- Person - Place - Time Important for aetiological hypotheses ( trying to find cause) Health service planning- if you know how many, you can allocate funds and resources

Question 95

What are the most commonly diagnosed cancers worldwide?

Answer 95

Lungs Breast Bowel Prostate

Question 96

Give an example of variation of incidence.

Answer 96

Cervical cancer - 3rd in Africa - 7th worldwide

Question 97

What is the most commonly diagnosed cancers in the UK?

Answer 97

Gender specific - Prostate in men - Breast in women Overall/non gender specific - Lung

Question 98

Changes in cancer incidence rates in males?

Answer 98

Increase: - Malignant melanoma not enough sun protection - Thyroid tx via radiation for other cancer types - Prostate active screening and picking up cases that wouldn’t have been before Decrease: - Bladder traditionally occupational due to chemical exposure, now more regulation - Lung - Stomach

Question 99

Changes in cancer incidence rates in females?

Answer 99

Increases: - Malignant melanoma - Thyroid - Kidney - Slight in breast because better screening and detection Decreases: - Bladder, ovary, oesophageal and stomach

Question 100

List examples of varying global incidence rates.

Answer 100

- Cervical --> ^^ in lower income, African countries - Stomach --> ^^ in China, possibly due to diet or other infections - Colorectal --> ^^ in westernized high income countries, diet, lifestyle differences

Question 101

Give explanation for high mortality rates (cancer).

Answer 101

Some present late and lack of available effective treatment - Lung, pancreas Some more treatable and number of deaths have gone down but due to high prevalence they’re still big killers

Question 102

How many people in the UK were living with cancer in 2008?

Answer 102

2 million

Question 103

Why is incidence and survival increasing?

Answer 103

- Ageing population - Earlier detection - Improved tx

Question 104

How do childhood cancers differ to adult ones?

Answer 104

Histopathologically different Clinically different - Tend respond to tx - Better survival rates

Question 105

How can epidemiology of cancer help?

Answer 105

Look at patterns to identify causes Look at reasons for high mortality: - is it access to care or late stage presentation - then try and make changes

Question 106

What is risk transition? Environmental risk transition is the process by which traditional communities with associated environmental health issues become more economically developed and experience new health issues. In traditional or economically undeveloped regions, humans often suffer and die from infectious diseases or of malnutrition. As economic development occurs, these environmental issues are reduced or solved, and people begin to suffer more often from diseases of excess or sedentism.

Answer 106

As a country develops the diseases affecting the population shift from infectious to non-infectious by: - Improvements to medical care - Ageing population - Public health interventions

Question 107

How many cancer deaths is tobacco associated with?

Answer 107

50-60%

Question 108

What is pre-disposition vs susceptibility?

Answer 108

Predisposition – due to rare gene mutations predisposing to specific diseases - Manifest as familial cancer syndromes e.g BRCA1 / 2 or FAP/APC gene Susceptibility - Genetic variants that make an individual more susceptible to certain types of cancer and may be linked to specific exposures

Question 109

What is the difference between primary/secondary/tertiary prevention?

Answer 109

Primary = reduce exposure Secondary = identify pre-clinical disease and prevent progression Tertiary = modify outcomes of clinical disease

Question 110

What is the probability of getting and dying from cancer?

Answer 110

1/3 in lifetime ¼ die from cancer

Question 111

When was the 5 year cancer survival rates for Britain the worst in Europe?

Answer 111

1980s | 1990s

Question 112

Where was the variation in 5 year survival rates within the UK?

Answer 112

Highest in south | Lowest in north

Question 113

Causes for poor UK performance?

Answer 113

- Differences in data collection between regions and between the UK and Europe - Age differences between the populations - Differences in the stages of presentation – UK patients presented later - Differences in social class and access to treatment marked socio-economic gradient

Question 114

When was the Calman-Hine report commissioned? Why was it commissioned?

Answer 114

1995 Response to evidence of poor UK survival rates in the Eurocare report

Question 115

What were the Calman-Hine reports main aims?

Answer 115

Examined cancer services in the UK, and proposed a restructuring of cancer services to achieve a more equitable level of access to high levels of expertise throughout the country.  All patients to have access to a uniformly high quality of care  Public and professional education to recognise early symptoms of cancer  Patients, families and carers should be given clear information about treatment options and outcomes  The development of cancer services should be patient centred  Primary care to be central to cancer care  The psychosocial needs of cancer sufferers and carers to be recognised

Question 116

What is the role of the MDT?

Answer 116

- Discuss EVERY NEW DIAGNOSIS on their site - Decide a management plan for each patient and inform primary care - Develop referral, diagnosis and treatment guidelines for their tumour sites according to local and national guidelines

Question 117

Who is in the MDT?

Answer 117

Medical staff = physician, surgeon, oncologist, radiologist, histopathologist, specialist nurses Extended = physiotherapist, dietician, palliative care

Question 118

When was the NHS cancer plan published?

Answer 118

2000

Question 119

What were the aims of the NHS cancer plan (2000)?

Answer 119

- First of its kind - Save more lives through better support, care, access to best tx - Tackle inequalities in health - Future investment in staffing, research and genetics of cancer - Covered aspects of: prevention, screening, dx, tx

Question 120

What did NICE use the NHS cancer plan (2000) for?

Answer 120

Producing improved guidelines for cancer care Manual of Cancer Standards

Question 121

How many people would cancer networks serve?

Answer 121

1-2 million people

Question 122

What were the key areas of action for the cancer reform strategy?

Answer 122

- Prevention - Earlier dx - Better tx - Better outcomes - Reduced inequalities

Question 123

What is the philosophical dualism of the body?

Answer 123

’I have a body’ and ‘I am a body’ Who we are and what we are made of

Question 124

What contributes to body image?

Answer 124

- Complex - Parents - Families - Communities - Life experience - Given guidance in various aspects of life so that we can match self-esteem with our abilities

Question 125

What do we experience as a dual entity?

Answer 125

- Biological bodies | - Social bodies

Question 126

What is the concept of physical capital?

Answer 126

- Our bodies give us a sense of certain status/ value | - We can ‘read’ bodies

Question 127

What is sex?

Answer 127

Biological essence/ determinants of gender

Question 128

What is gender?

Answer 128

Social differences and identity of men and women

Question 129

How much faster are eating disorders growing in men than women?

Answer 129

Twice as fast

Question 130

What has contributed to obesity?

Answer 130

Cheaper food Especially cheaper unhealthy food

Question 131

What are body dysmorphic disorders?

Answer 131

A mismatch between the inside and the outside Or Subjective and objective body image

Question 132

What are bodies linked to?

Answer 132

Sense of self and self-status Any threat to body integrity also threatens this

Question 133

What are the functions of clinical records?

Answer 133

- Record of contact with health care providers. - Aide memoire to facilitate communication with and about patients. - Improve Future Patient Care - Audit - Financial planning --> can see changing demographics and disease prevalence --> budgeting for future - Management - Research - Social purposes at the request of patients. - Medico-legal document ---> should always be prepared to defend what you have written in court

Question 134

What are the medical functions of the clinical record?

Answer 134

Support method of, and structure to, history and examination Ensure clarity of diagnosis – important in clinical reasoning Record treatment plans Enable comprehensive monitoring Help maintain a consistent explanation for the patient Ensure continuity of care – another health practitioner needs to read and understand your notes

Question 135

What do you record in a clinical record?

Answer 135

Presenting symptoms and reasons for seeking health care. Relevant clinical findings consider any red flags Diagnosis and important differentials also record any exclusions Options & decisions for care and treatment record the risks and benefits Action taken and outcomes Can be done by hand or computerised

Question 136

When can you remove information?

Answer 136

If it is duplicated, inaccurate If patient requests it despite reassurance about confidentiality

Question 137

Describe the medical records in community care.

Answer 137

Multiple records for different professionals – district nurses, social care etc. There is limited integration and links to hospitals and GP practices Single assessment process = for older people, aims to ensure NHS + social services treat elderly as individuals and let them make decisions regarding their care

Question 138

Describe medical records in secondary care.

Answer 138

Largely paper based Poor quality of computerisation

Question 139

Why do you use medical records in audit, research and management?

Answer 139

Facilitates clinical governance, risk management and resource management Hospitals and GPs have individual standards they must reach

Question 140

What are the rights of access?

Answer 140

- NHS Code of Practice = only disclose info that you have to and use minimal identifiable info, there is general acceptance amongst patients that info will be shared amongst healthcare workers for optimal treatment - Common Law of Confidentiality = case by case basis, can breach confidentiality if it is in the public best interest or if instructed legally - Data Protection Act = data owner and data controller don’t keep records longer than needed and protect them - Human Rights Act 1998 = respect for private and family life - Competence to Consent = patients can refuse to disclose info to third parties as long as they are competent

Question 141

What does critical reflection help you to do?

Answer 141

- Develop skills in life-long learning - Develop insight and self-awareness - Develop skills in understanding, analysing and questioning your practice and experiences - Understand and evaluate perspective of others - Identify strengths, weaknesses and training gaps - Writing about experiences or events from which you can learn - Being open and honest - Demonstrating a proper understanding of the issues about which you are reflecting on - Showing an awareness of how your behaviours and those of other people might affect others - Setting constructive and achievable goals

Question 142

Why is critical reflection important?

Answer 142

- Understand and evaluate arguments - To know when to challenge - To help make the right decisions - To be able to explain and justify your decisions

Question 143

How would you evaluate an argument and know whether or not to agree with them?

Answer 143

Step 1 - Is it logical? Step 2 - Is the argument valid? - - Does the conclusion follow the premise logically? - If the argument is valid, is it sound? - - Conclusion is only sound if it is true e.g if premises are so bizarre but it could still be valid just not sound - If answer to both for step 2 is “yes”, then argument is successful

Question 144

Why might an argument be invalid?

Answer 144

- Different premises may express different concepts - Confusing necessary with sufficient, and vice versa - Insensitive to the way in which claims are qualified - Argument begs the question - Conclusion is being supported by the premise (conclusion is assumed in premise)

Question 145

Why might an argument be unsound?

Answer 145

- Argument is invalid. - Argument is valid but one or more premise is false. - A premise might be false if: - - Makes a false/controversial moral claim - - Makes a false/controversial empirical claim

Question 146

What should you avoid in an argument?

Answer 146

- The straw man fallacy - misrepresentations - Ab hominems - evaluate argument based on person who said it - Appealing to emotion - Begging the question - Argument from fallacy - Just because argument is false, doesn't mean that the conclusion is false, other reasons, just that particular argument that failed

Question 147

If an argument is unsound, is the conclusion false?

Answer 147

- Even if an argument is unsound, does not mean the conclusion is false. - Perhaps there are other arguments for the same conclusion or maybe the original argument can be revised in a way that makes the argument more immune to criticism. - E.g. consider how someone could revise the argument against abortion in a way to block certain objections to premises.

Question 148

What are the differences between deductive and inductive arguments?

Answer 148

Inductive reasoning moves from specific instances into a generalized conclusion, while deductive reasoning moves from generalized principles that are known to be true to a true and specific conclusion. Inductive starts with a conclusion e.g tends to be scientific reasoning Deductive starts with premise e.g tends to be ethical reasoning

Question 149

What are the different disciplines that testing covers?

Answer 149

Biological tests - Hb count, Ca2+ levels, ALT levels Imaging - Radiographs, ultrasounds, MRIs etc Questions - CAGE questionnaire for potential alcohol problems Examination - Tactile vocal fremitus, hepatomegaly palpation

Question 150

Why do we carry out tests?

Answer 150

- To inform decisions | - To confirm what we believe is wrong with patient

Question 151

What is a true positive result?

Answer 151

The test result is positive in an individual with the disease.

Question 152

What is a true negative result?

Answer 152

Test result is negative in an individual wo/ the disease.

Question 153

What is a false positive result?

Answer 153

False positive - result is positive in person wo/ the disease

Question 154

What is a false negative result?

Answer 154

False negative - result is negative in individual w/ the disease

Question 155

What does a good test do?

Answer 155

Maximise the true positive and negatives Minimise the false positive and negatives

Question 156

What is sensitivity?

Answer 156

Number of true positives/all those with the disease Tests with a high sensitivity correctly identify a high proportion of individuals who actually have the disease If 100 patients known to have a disease were tested, and 43 test positive, then the test has 43% sensitivity

Question 157

What is specificity?

Answer 157

Number of true negatives/ all those without disease Tests with a high specificity correctly identify a high proportion who really don’t have the disease If 100 with no disease are tested and 96 return a negative result, then the test has 96% specificity.

Question 158

What are predictive values of a test?

Answer 158

- Reflect diagnostic power of a test - So if the test result is positive, what are the chances of the patient actually having the disease - Or if the result is negative, what are the chances the patient doesn’t have the disease

Question 159

What is the positive predictive value?

Answer 159

Number of true positives/All those who tested positive Chance of actually having the disease if result comes back positive

Question 160

What is the negative predictive value?

Answer 160

Number of true negatives/All those who tested negative The chance of not having the disease if your test is negative

Question 161

What is D-dimer? What does its presence suggest?

Answer 161

Degradation product of fibrin Clotting has occurred Its presence suggests DVT/PE

Question 162

What are the PPV and NPV for D-dimer tests? And what does this mean?

Answer 162

- High NPV - Lower PPV - Good at ruling OUT DVT, as high chance of not having disease if your test is negative - Not good at diagnosing it

Question 163

What does disease prevalence affect? Why?

Answer 163

- PPV and NPV changes - Sensitivity and specificity remain constant A good test will always correctly identify a certain % of people w/ or wo/ the disease

Question 164

What happens to PPV and NPV as prevalence increase?

Answer 164

- PPV increases - NPV decreases More people with the disease so chance of picking it up are higher

Question 165

What happens to PPv and NPV when prevalence decreases?

Answer 165

- NPV increases - PPV decreases Disease that is more uncommon means there are more people in the population without it, so it is easier to rule out

Question 166

Where does disease prevalence change?

Answer 166

- Between primary and secondary care populations different - Across age groups - Between countries

Question 167

What is likelihood ratio?

Answer 167

- Another way of summarizing performance - Assessing value of performing a dx test - Assess chances of disease after we have performed the test Use it to work out if it is worth carrying out the test and how much you should shift your suspicion for a particular test result

Question 168

What is the LR for positive test results (LR+)?

Answer 168

Chance of testing positive if you have disease/ chance of testing positive if you don’t have disease

Question 169

What is the LR for negative test results (LR-)?

Answer 169

Chance of testing negative if you have disease/ chance of testing negative if you don’t have disease

Question 170

What is the significance of LR+ and LR-?

Answer 170

The larger the LR+ the greater chance you have disease if your test is positive The smaller the LR- the less chance you have disease if your test is negative

Question 171

What is the pre-test probability?

Answer 171

Chances of disease before test = the disease prevalence in your population

Question 172

Define screening.

Answer 172

Systematic application of a test or inquiry to identify individuals at sufficient risk of a disorder to warrant further investigation or direct preventive action amongst people who have not sought medical attention

Question 173

What kind of approach is screening?

Answer 173

Population based

Question 174

Give 4 examples of screening.

Answer 174

- Heel-prick test for congenital diseases - AAA and ultrasound - Cervical cancer and smears - Bowel cancer and FOB

Question 175

What level of prevention is screening?

Answer 175

- Secondary (most) | - Because detecting early disease allows a potential for early and more effective treatment

Question 176

Does positive screening = diagnosis?

Answer 176

No Identifies those who need more dangerous/invasive definitive tests.

Question 177

What do you need to consider w/ the condition you screen for?

Answer 177

- Should be important justify effort - Epidemiology and natural history should be understood - Detectable risk factor Latent period (asymptomatic identification) - Already have cost-effective primary prevention implemented

Question 178

What do you need to consider w/ the screening test?

Answer 178

- Simple - Safe - Especially as exposing WELL people to it, so don’t want people put at risk - Precise - Validated - Consistent - Have a suitable cut off and have the test value distribution known - Agreed policy on further management

Question 179

What do you need to consider w/ the treatment after screening?

Answer 179

- Needs to be effective - Evidence of early treatment leading to better outcomes - Agreed policy on who should be offered tx - Clinical management should be optimized prior to screening programme

Question 180

What do you need to consider about the screening programme itself?

Answer 180

- RCT evidence it effectively reduces mortality or morbidity - Evidence ALL aspects are acceptable to professionals and public - Benefits > harms - - Screening actually harms patients - Opportunity cost of the programme should be balanced in relation to healthcare spending i.e shouldn’t deny something of greater value - Must have plan for quality assurance and adequate staffing and facilities

Question 181

Why do screening programmes need to be put through trial first? What should they not do?

Answer 181

- Selection bias - Length bias - Lead time bias Should not assess survival from point of diagnosis

Question 182

Define selection bias.

Answer 182

The people who come for screening tend to be healthier than those who don’t e.g. ’health screening effect’

Question 183

Define length bias.

Answer 183

Screening is best at picking up long-lasting and slowly-progressive conditions rather than rapidly-progressing poor prognostic ones

Question 184

What is sojourn time and how does it link to length bias?

Answer 184

- Sojourn time is the length of time tumour/disease spends in Asymptomatic/pre-clinical phase - Short= rapidly progressing --> poorer prognosis - Long = better prognosis - More likely to detect diseases with longer sojourn times - In whole population, there is people with lots of different long and short sojourn time diseases. - Those who are screened more likely to have long sojourn time because longer period they can be detected - Hence if you only measure survival from diagnosis you would have a disproportionate number of people with slowly progressing disease compared to normal disease population - Makes programme look better/more successful than it actually is

Question 185

What are the consequences of length bias?

Answer 185

- Diseases with longer sojourn time are easier to catch - Screen-detected disease has better prognosis than people who are symptomatic - Comparing individuals who choose to be screened with those who have disease = distorted picture - Basing RCT on ‘intention to screen’ includes full range of outcomes and assess impact of screening

Question 186

Define lead time.

Answer 186

The time between disease detection and clinical symptoms.

Question 187

Define lead time bias.

Answer 187

- Survival time after screen-detection appears longer because you start the ‘clock’ sooner - Additional time added to the length of patients disease due to it being picked up in presymptomatic phase by screening If we are measuring survival only: - A screened patient may die at the same time as a non-screened patient - The screening programme appears to extend survival but in reality all it does is cause the patient to live with the disease diagnosis for a longer period of time - If the disease outcomes cannot be changed regardless of screening then you are simply adding in additional lead time that is of no clinical importance

Question 188

What are the consequences of lead time bias?

Answer 188

Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time

Question 189

How do you appropriately measure screening effectiveness?

Answer 189

Death rates

Question 190

Thinking about the condition, why does colorectal cancer have a screening programme and not prostate cancer?

Answer 190

Colorectal - Biology of polyp-cancer progression reasonably well understood - Polyps/cancers bleed/can be seen - Primary prevention limited: ?diet, ?aspirin Prostate - Biology very poorly understood - High prevalence of clinically unapparent disease - Prostate cancer (plus other things) raises PSA in blood - Primary prevention doesn’t exist

Question 191

Thinking about the test, why does colorectal cancer have a screening programme and not prostate cancer?

Answer 191

Colorectal - Sensitivity of FOB (80-90%) - Specificity of FOB (90-98%) Prostate - True sensitivity/specificity unknown

Question 192

Thinking about the treatment, why does colorectal cancer have a screening programme and not prostate cancer?

Answer 192

Colorectal - Resection is of proven benefit - Less advanced stage = better survival Prostate - Number of tx options under investigation - One is ‘active monitoring’ basically no curative tx so the test isn’t justified?

Question 193

Thinking about the trials, why does colorectal cancer have a screening programme and not prostate cancer?

Answer 193

Colorectal - Number of trials reported - Over 20 years from starting trial to implementation Prostate - Number of trials in progress - Initial results reported in April 2009

Question 194

When thinking about whether to screen for a disease what do you need to assess? (summary)

Answer 194

- Condition - Test - Treatment - Trials

Question 195

What are the disadvantages of screening?

Answer 195

- Anxiety to patient - Risk of harm through screening procedure - Overdetection/overdiagnosis and overtreatment of things that might not have caused a problem in the first place - Interventions cause side effects and carry further risks

Question 196

Who does/doesn't benefit from screening?

Answer 196

True positives - Some will benefit others won’t True negatives benefit from less anxiety I guess but not much else

Question 197

What must be considered w/ reproductive ethics?

Answer 197

Interests of the parents - Procreative autonomy Interest of future child - Welfare of child, will it live poor life either to disability or harm from parents? Interest of 3rd parties - State, use of resources, ART can be expensive so this justifies limits on the number of cycles

Question 198

What are the objections to ART?

Answer 198

Involves destruction of human embryos which have potential to become a child: - Depends on moral status you assign to embryo, many will agree it is same as human - Even if same rights, would embryo take priority over mother if it becomes a danger to her health? It is harmful to those trying to conceive? - Success rate for IVF is low --> emotional harm? - Risks of multiple pregnancy --> higher risk of mortality and morbidity It is ‘unnatural’ and should not be playing God - Relatively weak - Much of medicine can be considered unnatural

Question 199

What is the open-future argument?

Answer 199

Children should be ensured a maximally open future i.e widest possible range of opportunities - Used as basis to terminate embryos with serious disabilities

Question 200

What type of right do parents have?

Answer 200

Negative right - To not be prevented from conceiving a child by the state Do not have a positive right for state-provided help/ intervention with ART Basically the State can’t stop parents from having children but it doesn’t mean they have to help them do it

Question 201

What are the legal aspects of ART? | What act is it laid out in?

Answer 201

Human fertilisation and embryology authority act 2008 - Welfare of child needs to be taken into account - Need for ‘supportive parenting’ hence valuing role of all (hetero and homo) parents - Sex selection/social selection of embryos is prohibited

Question 202

Why has the human fertilisation and embryology authority act been criticised?

Answer 202

Fertile couples don’t need to apply the ’welfare criteria’ why should it just be infertile couples? Predicting welfare of the child is hard - There is no guarantee over future circumstances of both the parents and child - Couples can put on facades to get the treatment

Question 203

How many ART cycles can 23-39 cycles have for free?

Answer 203

Up to 3

Question 204

What are other third party interests?

Answer 204

A child born with disability as a result of ART would be a further burden on the state

Question 205

What is pre-implantation genetic diagnosis (PGD)?

Answer 205

Screening cells from the embryos for detection of genetic/chromosomal disorders Considered acceptable for screening for genetic diseases e.g mitochondrial disease but not for sex selection/ characteristics

Question 206

What is the pro-life argument?

Answer 206

Abortion ends life of a foetus and is morally wrong Foetus has moral status of a human therefore identify it as a human with full moral status and abortion is the same as killing a human Therefore, It is wrong to kill a person/ creature that has same moral status as a human

Question 207

What is the pro-choice argument?

Answer 207

Mother has right to exercise control over her own body An embryo/foetus doesn’t have the same moral status as a fully-grown human

Question 208

What are the problems w/ moral status?

Answer 208

- Does it have the full status of a human - What stage does it assume this, conception, development or point of birth? - Potential to be a human- is it acceptable to assign moral status based on this? - - We don’t treat other things the same e.g we all have the potential to be corpses, but are not treated as such during life

Question 209

What are the legal aspects of abortion?

Answer 209

- Abortion act 1967 - Amended in 1990 - Not unlawful if 2 medical practitioners think: - - The pregnancy hasn’t exceeded 24 weeks and continuing the pregnancy would have a greater risk of injury to the mother, physical or mental, than if it were terminated - - The termination is necessary to prevent permanent injury to the mother – physical or mental - - Continuing the pregnancy would put the life of the mother at risk, greater than if it were terminated - - There is a significant risk of the child would suffer from physical/ mental abnormalities

Question 210

Are doctors allowed to refuse participation in termination?

Answer 210

- Yep, they have autonomy - Except emergencies then they have to whether they like it or not - However, compromises can be made e.g. referring to another doctor

Question 211

How do children and adult rights differ?

Answer 211

Same - Involved in decisions and have confidentiality Differ - Different decision-making and vulnerability

Question 212

Why are children of concern?

Answer 212

- Dependent on others to take care of them - May have underdeveloped decision-making capacities in terms of understanding - Undeveloped value systems which makes assessing their best interests difficult - Possess limited powers- physical, emotion and legal- to defend their rights

Question 213

What does the GMC state in regards to children?

Answer 213

Young people can be vulnerable, need protecting and help with decisions and defending their rights Respect rights of young people and their decisions + confidentiality take views seriously

Question 214

At which age are you presumed competent?

Answer 214

16-17 Must obtain consent If under 18, you can’t refuse treatments approved by parents or in your best interest

Question 215

How are decisions made in under 16s?

Answer 215

If Gillick competent, can make own decisions. The must... - Understand the nature + consequences of treatment/ no treatment - Retain the info and weigh it up - Communicate their decisions/ ideas clearly If not competent, then consent from someone with parental responsibility is sufficient - Mother/father (married or acquired parental responsibility) - Guardian of child/local authority - People with parental responsibility have a legal obligation to act in child’s best interests

Question 216

What happens if parents don't consent to Tx in child's best interest?

Answer 216

Take them to court

Question 217

What do best interests comprise of?

Answer 217

- Views of the child as far as they can express them - Views of the parents & others close to the child - Cultural, religious or other beliefs and values of child & parents - Views of other healthcare professionals involved in providing care - The choice that will least restrict child

Question 218

Define parental autonomy.

Answer 218

Parents should be allowed to make decisions regarding their children. - Because they know them best Can be overruled if child’s welfare is at stake. Complex tx issues = withholding tx, religious/cultural procedures.

Question 219

Pros and cons of making childhood immunisations mandatory?

Answer 219

Pros - Favours health of the public by lowering disease incidence Cons - Stops people making own choices on behalf of children, risk of harm from side effects

Question 220

Define the harm principle.

Answer 220

State intervention is justified if it is necessary to prevent greater harm to the public than not intervening.

Question 221

What do children have a right to be protected from?

Answer 221

- Abuse - Neglect - Rights to be involved in own care

Question 222

Confidentiality in regards to children?

Answer 222

Same as adults, especially to those who are competent Should ask permission before discussing case with parents Not an absolute obligation, info can be shared in child’s best interest

Question 223

When can you provide contraceptive, abortive and STI tx to people under 16 without parental consent?

Answer 223

Only if: - They understand all aspects of advice and refuse to involve parents. - Likely to have sex regardless of what you say. Confidentiality is key lack of it deters people from getting advice they need and thus endanger their own health If involved in abusive/harmful sexual activity then info should be shared with appropriate agencies.

Question 224

How many hospital deaths are thought to be avoidable?

Answer 224

6%

Question 225

List why hospital deaths are thought to be avoidable.

Answer 225

Poor monitoring Diagnostic errors Drugs etc EBM is absent Pharmaceutical companies don’t publish all trials, makes thorough systematic reviews of all evidence difficult --> lead to disasters e.g Vioxx

Question 226

Types of medical errors?

Answer 226

Medication e.g incorrect drug, severity depends on situation e.g chemo vs painkillers Surgery e.g wrong procedure ---> WHO checklists Infection control - what is efficient level of error? Zero?

Question 227

What was introduced to reduce MRSA and C.diff?

Answer 227

Reporting and penalties

Question 228

What are 'never ever' events?

Answer 228

- Shouldn’t ever happen - E.g incorrect blood transfusion - Get penalties and fines

Question 229

What are patient reported outcome measures (PROMs)?

Answer 229

Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering 4 clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys. ``` The four procedures are: hip replacements knee replacements groin hernia varicose veins ``` PROMs measure a patient’s health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients.

Question 230

Why do we need consumer protection?

Answer 230

Medical practice internationally had 3 deficiencies: - Medicine overall has a weak evidence base. - Large variations in clinical practice – we give different treatments to patients who are similar in need. - Failure to measure success/ outcomes in healthcare – we measure mortality but this is a limited outcome.

Question 231

What data is available to improve patient safety?

Answer 231

 Hospital episode statistics (HES) - Details referring GP, procedures given, duration of stay and discharge/death  Patient reported outcome measurements (PROMs) - compares quality of life before an after procedure  Reference cost data - Cost data are poor

Question 232

What is the hospital level mortality indicator (2012)?

Answer 232

Mortality rates within 30 days of discharge compared to expected mortality given hospital characters Need to be adjusted for age and severity of conditions The ratio between the actual number of patients who die within 30 days of discharge compared with the number that would be expected to die on the basis of average

Question 233

What are the different consumer protection agencies?

Answer 233

- CQC (care quality commission) - NICE (National Institute for Health and Care Excellence) - DoH and NHS England - oversight of cost and quality control - GMC- regulates medical schools and practitioners - Royal colleges - examine and certify practitioners

Question 234

What is the role of CQC (care quality commission)?

Answer 234

- Regulates quality and financial performance of all healthcare providers – public and private - Licensing of all healthcare providers without this cannot trade - Policing: unannounced visits and inspections use the HES data Monitor: - Regulation of finances AND quality of Foundation Trusts only - Competition policy and hospital tariffs – Pay by Performance

Question 235

What does NICE do?

Answer 235

- Appraise new technologies - Produce clinical guidelines - Advise on cost-effective public health interventions

Question 236

In what way is family structure changing?

Answer 236

Increasingly smaller, single and step-parenting families

Question 237

What is the social context of pregnancy and childbirth in a professional and ideological context?

Answer 237

Professional - Doctors Vs midwives who has authority Ideological - Nature Vs technology - Home Vs hospital - Private Vs public (pure Vs polluted)

Question 238

Name some inequalities.

Answer 238

Poverty and income Poor nutrition - endanger both mother and child Access to health and social care – varied may not always meet needs Ethnicity and experience of health inequalities Internationally - Niger- maternal mortality is 1 in 7

Question 239

What is pollution in context of childbirth and pregnancy?

Answer 239

- Many aspects are regarded as ‘polluting’ - Unwashed baby, blood, placenta etc - There are cleansing practices in some cultures - Some forbid male practitioners from carrying out internal examinations - Only recently have men had role in birthing process

Question 240

What is medicalisation?

Answer 240

The process by which events seen as ‘normal’ in life are overtaken by medical practice.

Question 241

What are some of the medicalisation that have taken place?

Answer 241

Moved from all female domain to medicalized sphere involving men Changes: - Public to private behind closed doors - Midwife to doctors + nurses - Natural to medical - Home to hospital – due to concerns over maternal + infant mortality e.g. Puerperal fever: - - People wanted pain relief and safety – ‘rich’ people were seen as not suffering so others also wanted this, why should others suffer with no support? - - Cleanliness – although not as clean as we think - - Higher status – elitism of having child in hospital - - Being cared for after birth

Question 242

What was the maternity matters (2009) guideline?

Answer 242

Gives choice to mother about care, continuity of care and safe service

Question 243

What is the role of midwives?

Answer 243

- Used to just be wise women in the community but then had Royal college established (1947). - Effect on medical practice = create a ‘home-like’ environment. - Don’t separate child and mother and include mother in all decisions.

Question 244

What are the regulations around C sections?

Answer 244

2011 NICE guidelines State all mothers should be given right to choose a c-section if they wish Even if there is no clinical indication for one

Question 245

What are childhood illnesses in lower income countries mainly caused by?

Answer 245

Infection

Question 246

Name the major childhood illnesses in high income countries?

Answer 246

Injury/poisoning - 90% accidental - 20% of all deaths 1-5 yrs - 1mn + A&E admissions Cancer - 20% of all deaths, most child cancer is malignant CNS diseases Congenital abnormalities - 3%

Question 247

What are the major childhood illnesses in low/middle income countries?

Answer 247

- Diarrhoea - Pneumonia - Malaria - HIV/AIDs - Measles - Neonatal disorders

Question 248

How much of A+E paediatric admissions are a result of falls?

Answer 248

50%

Question 249

What are the most common childhood cancers?

Answer 249

- Leukaemia - Lymphoma - CNS and brain

Question 250

What is included under perinatal?

Answer 250

- Delivery - Infection - Congenital

Question 251

Name acute CNS illnesses?

Answer 251

- Meningitis - Meningoencephalitis - Febrile convulsions – URTI with fever, bilateral convulsion need to distinguish from seizure - Seizure disorder e.g. epilepsy - Vascular – AVM causing stroke - Congenital

Question 252

Name acute respiratory illnesses.

Answer 252

URTI – tonsillitis, croup (parainfluenza), tracheitis (S.Aureus) LRTI – bronchiolitis (RSV), asthma Pneumonia – viral, bacterial, atypical Foreign body inhalation right bronchus

Question 253

List acute GI illnesses.

Answer 253

Vomiting: - Medical = gastroenteritis, GORD, sepsis, food intolerance - Surgical = pyloric stenosis, malrotation, intussusception Acute abdominal pain = appendicitis, gastritis etc. Gastroenteritis Inflammatory bowel disease Diarrhoea: - Infective most common worldwide - Malabsorption - Food intolerance - Constipation = common cause

Question 254

Significance of UTI under 6 months?

Answer 254

Need ultrasound to look for any structural abnormality e.g horseshoe.

Question 255

Name common public health measures.

Answer 255

- Seatbelts for accident prevention - Immunisation - Antenatal and neonatal checkups and blood spot tests for conditions such as hypothyroidism

Question 256

Name the common chronic illnesses.

Answer 256

- Asthma - Epilepsy - Diabetes - CF - IBD

Question 257

What are the implications of chronic illnesses?

Answer 257

Child = physical, mental, social Repeated absence at school Affects parents and siblings Significant financial for both family and community National health = provision and planning

Question 258

How many children are obese and overweight (<5yrs)?

Answer 258

1/6 obese 1/3 overweight

Question 259

How much of the world’s population live in a country where obesity kills more people than being underweight?

Answer 259

65%

Question 260

Name the risk factors for childhood obesity.

Answer 260

- Parental obesity - Gestational diabetes - Less than 6mths exclusive breastfeeding - Weaning onto high-fat/sugar foods - Poor diet + low physical activity

Question 261

How many deaths under 5 are preventable?

Answer 261

2/3

Question 262

What is the proportion of all childhood deaths for Africa and South-East Asia?

Answer 262

75%

Question 263

What were the major causes of death?

Answer 263

- Preterm – 1 million - Pneumonia - Diarrhoea - Malaria

Question 264

What are the risk factors of death in of under 5s?

Answer 264

- Low birth weight - Malnutrition - Non-breastfed children - Indoor air pollution

Question 265

What are the preventative measures for death of under 5s?

Answer 265

Vaccination - conjugated vaccine as immature immune system can’t respond to coat adequate nutrition and breastfeeding encouragement

Question 266

What is the causes of pneumonia in children?

Answer 266

Bacterial - Strep pneumococcus - Polysaccharide capsule that an immature immune system can’t fight Viral - Resp. syncytial virus is the most common cause of lower RTIs + viral pneumonia

Question 267

What are RF for diarrhoea in children?

Answer 267

- Non-breastfed - Unsafe water and food - Poor hygiene - Malnutrition- zinc in particular

Question 268

What are Tx for diarrhoea?

Answer 268

- Oral rehydration salts | - Zinc supplements

Question 269

What prevents diarrhoea in children?

Answer 269

- Exclusive breastfeeding safe water and food - Adequate sanitation - Vaccination

Question 270

What are the causes of diarrhoea in children?

Answer 270

Gastroenteritis: - Viral (Rotavirus/Norovirus) - Bacterial

Question 271

What is the RF for malaria?

Answer 271

- Young children - Endemic areas - Lack of vector control (parasite) - HIV/AIDs - Drug and insecticide resistance

Question 272

What is the Tx for malaria?

Answer 272

- Supportive | - Artemisnin-based combo therapy

Question 273

What is the prevention for malaria?

Answer 273

- Insecticide- treated nets- v.effective - Indoor residual spraying - Chemoprophylaxis in endemic regions

Question 274

What are the causes for malaria?

Answer 274

- Plasmodium parasite | - Most common (P. falciparum)

Question 275

When is the highest risk for death?

Answer 275

- Neonatal period | - First 28 days

Question 276

What is the single largest cause of childhood death?

Answer 276

- Preterm birth | - 10% of all births

Question 277

What are the short term problems for preterm births?

Answer 277

- Infection - Resp difficulties - Feeding problems - Jaundice

Question 278

What are the long term effects of preterm birth?

Answer 278

- Neuro-disability e.g cerebral palsy - Chronic lung disease - Poor growth

Question 279

How do you minimise health risk to newborns?

Answer 279

Quality care and nutrition during pregnancy + maternal immunisation Safe delivery Quality neonatal care: - immediate breathing - warmth care - early breastfeeding

Question 280

How many children are affected by malnutrition?

Answer 280

20 million globally More vulnerable to illness and death Can be treated at home with ready-to-use therapeutic foods

Question 281

What is included in personal beliefs and values?

Answer 281

- Moral - Political - Religious beliefs - Non-cognitive attitudes e.g. desires and emotions

Question 282

How can personal beliefs and values impact positively?

Answer 282

Compassion and care

Question 283

What is the importance of personal beliefs and values in medical practice?

Answer 283

Motivate doctors to do the right things e.g. caring for patient makes it more likely that we will treat well Makes doctors more perceptive + attentive to patients needs and priorities

Question 284

What is the problem with personal beliefs?

Answer 284

When they impact negatively on practice Interfere with people’s right to be treated in certain ways Cause harmful and neglectful behaviours less attentive/ uncompassionate doctor Be a source of offence or upset: - Certain attitudes may frighten others and cause anxiety Patients want empathy and to be valued can damage doctor-patient relationship if this is lacking

Question 285

What are the GMC professional expectations?

Answer 285

Must not express beliefs to patients in ways that exploit them or cause distress. Must not refuse or delay treatment because you feel patient caused their condition. Must not discriminate against patients or colleagues.

Question 286

Can doctors act in accordance with their beliefs?

Answer 286

Yes | So long as it does not negatively interfere with their clinical practice.

Question 287

What is conscientious objection?

Answer 287

Refusal to perform a legal role or responsibility because of moral or other personal beliefs e.g. in abortion.

Question 288

What is the problems with conscientious objection (CO)?

Answer 288

Procedures are lawful and in patient's best interests. Failure to receive them could be harmful and could be argued that allowing objection is inequitable and waste of resources.

Question 289

What is conscientious objection important?

Answer 289

Could be damaging to force a doctor to do something that they object to and goes against their moral integrity.

Question 290

Is CO allowed?

Answer 290

Yes so long as it doesn’t result in direct or indirect discrimination against patients Can’t treat one group of px because of your views on them e.g OCP and married v unmarried women

Question 291

What does the GMC say about conscientious objection?

Answer 291

You must make sure the patient is aware of your objection in advance – do this in a way that does not cause distress You should be open with employers and colleagues so that it can be worked around Ensure patient has all the adequate info to see another practitioner – don’t necessarily have to refer directly! However if it is not practical for them to arrange it you must do it for them e.g. vulnerable patient In emergency, must put objection aside to save px

Question 292

WHat happens when personal beliefs of patients interferes with your decision making?

Answer 292

Should provide procedures requested if they are of overall benefit to the patient this encompasses religious and cultural beliefs. If you do not believe the treatment is of overall benefit then you are not obliged to provide it.

Question 293

Define adverse event.

Answer 293

An unintended event resulting from clinical care and causing px hrm e.g wrong drug, falling, misdx. Not all arise from mistakes, some just because of risk of a procedure.

Question 294

Define near miss.

Answer 294

Events or omissions that arise during clinical care but don’t develop far enough to cause injury to a px, may or may not involve compensating action.

Question 295

What is the frequency of adverse events?

Answer 295

11%

Question 296

How many adverse events were preventable?

Answer 296

31%

Question 297

Define side effects.

Answer 297

These are known effects besides the intended primary effect of medication that can cause harm from justified action. Balance of risks and benefits that need to be shared e.g gentamicin and deafness.

Question 298

What are the direct cost of adverse events in additional hospital days?

Answer 298

£2bn 16,000 px claims lodged in 2012/13 20% relate to obstetrics, which account for 80% of cost of all claims

Question 299

What was the Berwick report?

Answer 299

Mid Staff NHS trust Focus on mistakes as a learning opportunity for development culture change

Question 300

What did the Keogh review find?

Answer 300

Safety processes are often not understood hence not implemented. Findings of patient safety investigations need to be shared and lessons learned. At-risk population needs to be easily identified.

Question 301

Why are standard mortality rates not fit for purpose?

Answer 301

People who come into hospital are sick, 50% of all deaths occur in hospital (on average) so hospitals essentially manage death, hence we cannot look at the quality of care based on death rate. SMRs are dependent on non-hospital care: - Proportion of people who die in hospital varies across different areas, reflects availability of other resources such as hospices. - Increased hospices = reduced hospitals SMRs but doesn’t affect total death rate.

Question 302

Name some alternative approaches to make standard mortality rates (SMR) work.

Answer 302

- Data vagaries/coding - Argue it could be coded if people are coming in to hospital to die so not taken into account for SMR - Problem - coding is poor across the country

Question 303

Are hospitals with high SMRs providing poor quality care?

Answer 303

- No | - No data to show any relationship between quality of care and SMR rate

Question 304

What is the prism study?

Answer 304

Looked at the percentage of preventable deaths in hospitals found to be only 5%. Also found that the correlation between death preventability and hospital SMR was almost 0 therefore using SMRs as a measure of care quality is stupid. On average a preventable death required 3 problems in care/ 5 contributory factors per case.

Question 305

How many problems/contributory factors are needed for a preventable death - prism study?

Answer 305

3 problems in care | 5 contributory factors

Question 306

What is the swiss cheese model?

Answer 306

Adverse events do not tend to occur because of a single factor, normally several contributory factors. Adverse events are a mixture of: - Latent conditions = system failures in the background - Active failures = failures in the frontline of delivering care Look at why something went wrong and what happened along the way.

Question 307

Define active failure.

Answer 307

Unsafe acts committed by people in direct contact with patient e.g. giving wrong drug

Question 308

What are the types of errors?

Answer 308

Knowledge-based = inadequate knowledge or experience i.e. bluffing + don’t actually know working beyond competence. Rule-based = apply wrong rule or misapplication of a good rule e.g. treatment regimen for 10-15yr olds given to a small 10yr old overdose. Skills-based = attention slips and memory lapses, unintended deviation of actions from a good plan e.g. pharmacist interrupted whilst preparing antibiotic who then forgets.

Question 309

List the types of violations (intentional rule breaking).

Answer 309

Routine Situational Reasoned Malicious

Question 310

What is routine violations?

Answer 310

A violation that has become normal behaviour within a peer group.

Question 311

What is situational violations?

Answer 311

Context dependent e.g. time-pressure, lack of supervision i.e. you know it is wrong but there is no-one to ask.

Question 312

What is reasoned violations?

Answer 312

Believed to be in patient’s best interest.

Question 313

What is malicious rule breaking?

Answer 313

Deliberate act intended to harm.

Question 314

What are latent conditions?

Answer 314

Develop over time and lay dormant until they combine with other factors or active failures to cause adverse events long-lived but can be identified and removed Examples: - Working environmental conditions e.g. long shifts/ bad patterns meaning tired staff - Training of staff poor training - Socio-cultural factors

Question 315

What is blame culture?

Answer 315

You are responsible because it was your mistake Hinders learning from them People will cover up errors for fear of punishment, hide true cause of failure

Question 316

What is normalisation of deviance?

Answer 316

Staff become blind to what is happening and assume practices are normal So when bad practice becomes normal because everyone is doing it

Question 317

What type of culture does the NHS need?

Answer 317

- Safety culture (not blame culture1) | - Promotes learning from mistakes

Question 318

What are some situations associated with increased risk of error?

Answer 318

- Unfamiliarity of task - Inexperience - Shortage of time - Inadequate checking - Poor procedures - Poor human equipment interface

Question 319

Give ways which one can decrease risk of error?

Answer 319

- Avoid reliance on memory - Make things visible - Review and simplify process - Standardise common processes - Routinely use checklists - Decrease reliance on vigilance - DESIGN OUT ERROR - E.g. surgical safety checklist reduced postop complication and death by 33%

Question 320

Which domains are child development split into?

Answer 320

- Physical - Cognitive - Emotional/social

Question 321

Is child development continuous or discontinuous?

Answer 321

Continuous - smooth process/curve, where children accumulate more of same types of skills. Discontinuous - occurs in steps. Rapidly change as they progress to a new stage of development, then little change for a while. With each new step, child responds and interprets world in a different

Question 322

Describe continuous child development.

Answer 322

Smooth process/curve, where children accumulate more of same types of skills.

Question 323

Describe discontinuous child development.

Answer 323

Occurs in steps. Rapidly change as they progress to a new stage of development, then little change for a while. With each new step, child responds and interprets world in a different way.

Question 324

Does child development follow one universal course, or many?

Answer 324

Children have similar anatomy, so assume that developmental stages are universal across children and cultures. Others believe children grow up in distinct environments and development is determined by the unique combination of influences around them, which results in significantly different social skills, cognitive abilities and feelings re oneself and others.

Question 325

Is development due to nature or nurture?

Answer 325

Age-old and still ongoing debate Nature refers to inborn biological factors, such as hereditary information each child received from conception. Emphasises genetic influence. Nurture refer to complex range of factors in physical and social world which influence child before and after birth. Emphasises learning from environment.

Question 326

Is the course of development stable or subject to change?

Answer 326

Nature- largely stable over time e.g IQ and effect of early traumatic events can’t be fully overcome in later life. Nurture- more optimistic, change is always possible, depending upon environmental influences.

Question 327

What are some of the important developments that take place during the first 3-5 years of life?

Answer 327

- Self-regulation - Communication and language - Language difficulties - Establishing relationships with others - Establishing secure attachment relationships - Peer relationships - Social understanding

Question 328

What are prenatal experiences that can affect child development?

Answer 328

- HIV infection - Maternal depression during pregnancy - Drugs etc

Question 329

What postnatal experiences have an adverse effect on child development?

Answer 329

- Global deprivation - Postnatal depression - Quality of infant day care

Question 330

How does Berk (2000) describe emotional and social development?

Answer 330

- Emotional communication - Understanding of self - Ability to manage feelings - Knowledge about other people - Interpersonal skills - Friendships - Intimate relationships - Moral reasoning and behaviour

Question 331

How can you categorise emotions/feelings?

Answer 331

- Positive affect (joy, happy, hope) | - Negative affect (fear, anger, sadness)

Question 332

What are the 3 predominant functions of emotions?

Answer 332

- Adaptation and survival - Regulation - Communication

Question 333

How do adolescents develop socio-emotionally?

Answer 333

Social cognition, i.e. ability to think about people + social relationships Increased understanding of morality + social conventions, e.g. justice, equality Growing awareness of social conventions + function they serve ‘Identity crisis’ in adolescence (Erikson, e.g. 1950) Peer acceptance, popularity + rejection

Question 334

Name Erikson's psychosocial stages (1950).

Answer 334

- Basic trust vs Mistrust (0-1) - Autonomy vs Shame (1-3) - Initiative vs Guilt (3-6) - Industry vs Inferiority (6-11) - Identity vs Confusion (teens)

Question 335

What did Paget (1952) assert?

Answer 335

That middle childhood (6-12) is especially important and is largely spent in primary school. Middle childhood is characterized by use of rules or strategies for examining and interacting with world.

Question 336

What are the Piaget stages of cognitive development?

Answer 336

- Sensorimotor period (0-2) - Preoperational period (2-7) - Period of concrete operations (7-11) - Period of formal operations (11+)

Question 337

What are the 4 terms Piaget uses to explain course of cognitive development?

Answer 337

Schemes - basic unit of cognition or understand about an aspect of the world Adaptation - Mechanism through which schemes develop as result of adjusting to changes. Adjustment possible through processes of assimilation and accommodation. Assimilation - Way we take information and perceptions, such that they fit in with/are compatible with our current understanding of the world. Accommodation - Process whereby person changes and alters cognitive structures to incorporate new experience of information.

Question 338

How does Santrock (1996) describe language development?

Answer 338

Infancy: - Vocalisation starts with babbling about (3-6 mths) - 1-2 word utterances appear about (12-26 mths) - 2-3 word phrases usually occur (27-34 mths) - 3-4 word phrases used around (35-46 mths) [see Brown's 5 stages of Mean Length of Utterance-MLU: useful indicator of language maturity, e.g. Brown, 1973] Early Childhood: - ~4 y/o, child shows sound understanding and use of language; hold meaningful convo with adult. Middle and Late Childhood: - Understanding and use of progressively more sophisticated vocabulary and grammar (syntax).

Question 339

What is the theory of multiple intelligences?

Answer 339

Gardner’s 1973 8 different intelligences all of equal importance: - Linguistic intelligence (eg language skills). - Musical intelligence (eg musical skills). - Logico-mathematical intelligence (eg logical reasoning skills). - Spatial intelligence (eg visuo-spatial skills). - Bodily-kinesthetic intelligence (eg athletic skills). - Interpersonal intelligence (eg people skills). - Intrapersonal intelligence (eg self-awareness). - Naturalist intelligence (eg outdoor/observational skills).

Question 340

Define developmental psychopathology.

Answer 340

Rolf and Read (1984:9) Study of abnormal behavior within a context of measuring the effects of genetic, ontogenetic, biochemical, cognitive, affective [emotional], social, or any other ongoing developmental influence on behavior.’

Question 341

Examples of developmental psychopathology.

Answer 341

Schizophrenia in childhood Depression in childhood Learning disabilities (e.g. dyslexia) Attention deficit disorder (ADHD) Learning problems due to toxic substances (e.g. lead) Autistic Spectrum Disorder (ASD) Sensory impairment (e.g. language problems linked to hearing impairment) Homelessness and poverty affects child’s growth & development

Question 342

What are 2 of the most significant experiences a child can miss?

Answer 342

Opportunity to develop self-reliance in terms of manipulating environment --> adverse effect on cognitive development. Opportunity to engage with others socially --> adverse effect on social & emotional development.

Question 343

What are indicators of social dysfunction?

Answer 343

- Victimised, ostracised, stigmatised by others -> low self-esteem - Poor relationships with others - Social withdrawal - Inappropriate social behaviour

Question 344

What are indicators of social well-being?

Answer 344

- Social competence (eg social skills) - linked to +ve self-esteem - Rewarding personal + social relationships with others - Communication skills - Appropriate social behaviour

Question 345

List indicators of emotional well-being vs dysfunction.

Answer 345

Indicators of emotional well-being (linked to social), eg: - Stable + secure attachments to significant others (eg parents) - Emotions appropriate to context - Positive self-esteem - Generally happy + optimistic outlook on life Indicators of emotional dysfunction (linked to social), e.g.: - Unstable + insecure attachments to significant others (eg parents) - Emotions inappropriate to context - Poor self-esteem - Anxiety + depression

Question 346

What are indicators of cognitive functioning vs dysfunction/impairment?

Answer 346

Indicators of cognitive functioning: - Functioning at age appropriate level (eg school work) - Appropriate progress in cognitive development - Child has positive + realistic perception of cognitive abilities - Given opportunities to reach individual potential Indicators of cognitive dysfunction/impairment: - Underachievement or limited cognitive ability - Lack of expected progress in cognitive development - Child has negative or unrealistic perception of cognitive abilities - May require special education provision to reach potential

Question 347

Define labour.

Answer 347

The sequence of actions by which a baby and the afterbirth (placenta) are expelled from the uterus at childbirth” (Martin, 2010: 405) which normally occurs spontaneously between 37 and 42 completed weeks gestation (Tiran, 2008)

Question 348

When was the midwives institute formed?

Answer 348

1881

Question 349

When was the first midwives act set out?

Answer 349

1902 Enshrines normality in childbearing as the midwife’s role, referring to doctors as soon as abnormality occurs

Question 350

What are the pros of institutionalisation of childbirth?

Answer 350

- Standardisation of care - Access to good facilities to support childbirth - Availability of populations of childbearing women and infants for the purposes of midwifery and obstetric training - Faster access to emergency care - Access to effective obstetric analgesia

Question 351

What are the cons of institutionalisation of childbirth?

Answer 351

- Medicalisation of childbearing. - Depersonalisation/ dehumanisation of birth. - “With institution”, rather than “with woman” mentality (i.e. serving the needs of the organisation). - Lack of privacy, constant scrutiny. - Inflexibility in labour and birth practices. - Limitation of resources. - Interventionist approach, favouring mechanisation and pharmacological solutions, and women’s passivity. - Defensive practice rather than sound clinical decision making. - The place of birth effects the way women give birth. - A culture of risk and suspicion surrounding birth.

Question 352

What is the medical model of birth?

Answer 352

Birth seen as: - The most dangerous journey - Only normal in retrospect - Therefore assume the worst (shoot first ask questions later) Low threshold for intervention (to fix the defective bodies) - Induction of labour - Augmentation of labour - Strict time thresholds for progress - Frequent assessment of progress in labour - Continuous electronic foetal monitoring - Directed pushing - Active management of third stage - Epidural anaesthesia - Liberal use of episiotomy - Restricted maternal movement (bed births) - Instrumental vaginal births - Elective/ Emergency caesarean - Labour in an obstetric unit - Close observation (management of birth)

Question 353

What is the social model of birth?

Answer 353

- Birth as a normal physiological process, which women are uniquely designed to achieve. - Support the capability of the women’s bodies - Home from home environment - Ambulation - Use of different positions to give birth - Use of other supportive measures such as bath for pain management and pool for labour and birth - Low tech, use of Pinard (foetal stethoscope) - Birthing balls - Birth stools - Watchful waiting/ patience - Use of massage, touch, encouragement

Question 354

What is the P-value and how do you interpret it?

Answer 354

The p-value is a statistical value used to determine the strength of evidence in a study Basically you want the smallest value as possible If it is < (or equal) 0.05 then it is strong and you can reject the null hypothesis (that the two variables are statistically independent from each other) However, if it is >0.05 then it indicates weak evidence and so you fail to reject the null hypothesis

Question 355

Define research.

Answer 355

A structured activity which is intended to provide new knowledge which is generalisable and intended for wider dissemination.

Question 356

How is research different to a clinical audit.

Answer 356

Clinical audit: is a way of finding out whether you are doing what you should be doing by asking if you are following guidelines and applying best practice. Research: evaluates practice or compares alternative practices, with the purpose of contributing to a body of knowledge by asking what you should be doing.

Question 357

Give examples of research atrocities.

Answer 357

Nazis medical experiments (Nuremberg trials) Willowbrook study - 1963-1966- Studies on infective hepatitis took place at Willowbrook State school in New York (institution for “mentally defective persons”). Tuskegee syphilis study - 1932-1972 by US public health service. Observe natural progression of untreated syphilis in rural African-Americans in Alabama, under guise of free health care from the government. Alder Hey - Unauthorised removal, retention and disposal of human tissue between 1988-1995 let to Human Tissue Act 2004. Wakefield - Dick that said MMR vaccine caused autism, also acted without ethics approval, making him even more of a twat.

Question 358

What resulted from the nuremberg trials?

Answer 358

Nuremberg code (1947) Research ethics principles: - Voluntary consent - Avoid fill unnecessary physical and mental suffering and injury - Conducted only by scientifically qualified persons

Question 359

What is the Helsinki declaration (1964)?

Answer 359

World Medical Association Requirement that any human research is subject to independent ethical review and oversight by properly convened committee. (Article 13)

Question 360

What are some of the key research ethics principles?

Answer 360

- Usefulness - Necessity - Risks - Consent - Confidentiality - Fairness - Approval

Question 361

Define consent.

Answer 361

Permission for something to happen or agreement to do something.

Question 362

What are some of the ways of facilitating consent?

Answer 362

- Information sheets - Summary of key points - Presentation of information - Opportunity to ask questions - Time to decide (at least 24 hours)

Question 363

What should participant information sheets contain?

Answer 363

- Purpose of study - What will happen if take part - Risks and benefits of taking part - What if study stops/something goes wrong - How privacy will be respected - Ethics review

Question 364

What makes consent voluntary?

Answer 364

Not putting pressure on patients or volunteer Not offering inappropriate (financial) enticements Not threatening/imposing sanctions

Question 365

When is consent not required for the use of human tissue?

Answer 365

Not required to obtain consent to use tissue from living patients if the tissue is anonymous to the researcher and the project has ethics approval.

Question 366

Can children give consent for the use of their tissues for research?

Answer 366

Yes, but only if Gillick competent. This includes before death (should include those responsible for the child though)

Question 367

Define confidentiality.

Answer 367

Principle in medical ethics that the information a patient reveals to a health care provider is private and has limits on how and when it can be disclosed to a 3rd party. Essential for trust in the patient-doctor relationship.

Question 368

What are guidelines for confidentiality?

Answer 368

All patient information is confidential. Research using identifiable personal information or anonymised data from the NHS not already in the public domain must have ethics approval. Coded and anonymized as far as possible. All information must be secured securely.

Question 369

When is research ethics approval needed?

Answer 369

When there is human parts, tissue, data on lifestyle, housing, working environment, attitude, animals or other organisms.

Question 370

Why is having ethics approval good?

Answer 370

Minimise harm Funding Publishing Minimise personal responsibility Protect participants and researcher (adhered to accepted ethical standards ^ recruitment potential!)

Question 371

Who do you get approval from?

Answer 371

- External body (e.g. NHS) | - Department / subject level committee

Question 372

What is the most common type of waiting list policy?

Answer 372

Some formof maximum waiting time guarantee.

Question 373

Why do we need to manage waiting lists?

Answer 373

Limitless demand for health services people can always be more healthy, which creates high demand. Limited resources – supply of money, staff etc is finite.

Question 374

How can you ration healthcare?

Answer 374

By ability to pay - Normal market response US system By need - Based on ability to benefit from care - Waiting lists used to prioritise but who? - - Raises ethical issue, purely clinical or based on social situation e.g. single mum?

Question 375

How do you measure waiting lists?

Answer 375

- Average waiting time - Who waited longer than x days/months - Average wait of people on the list

Question 376

What does a backlog imply?

Answer 376

Need for financial injection.

Question 377

Why can long waiting lists be good?

Answer 377

Deter frivolous use Resources constantly fully employed - Spare capacity waste of money, employment etc.

Question 378

What do waiting lists improve with?

Answer 378

More doctors More funds (not according to Jeremy)

Question 379

What is activity base remuneration?

Answer 379

Paying doctor per item of service they provide e.g. £50 per death certificate. Paying hospital per activity e.g. get a certain amount to perform a certain number of ops.

Question 380

What did the 2000-08 policies introduce?

Answer 380

Performance management of trusts and RCTs based on achievement of targets. Overall inpatient, outpatient, specialty and A+E. Hospitals received an overall performance score and managers could lose their jobs if they missed targets. - Worked as long waits went down.

Question 381

What were the downsides to the implementation of the 2000-08 policies?

Answer 381

Sacrifice of professional autonomy - Managers press doctors, forced to treat less urgent due to waiting time - Unmeasured performance suffers - Adverse behavioural responses - - Data manipulation and fraud - -- Emergency patients kept in ambulances rather than A +E, clock doesn’t start until px is through the doors

Question 382

What are the current challenges in the NHS?

Answer 382

NHS overall manages to maintain the targets. Except for emergency where its getting worse. 18 week RTT challenging - Lots of effort and still need to try and maintain priority - ^ demand and financial restraint

Question 383

What are the consequences for falling off NHS target?

Answer 383

90% expected to be treated within 18 weeks Breach – reduction of up to 5% of revenues for the speciality in that month

Question 384

What are alternative possible criteria to manage waiting lists?

Answer 384

- Clinical urgency/severity - Potential health gain - Productivity and been less - Equity waiting lists e.g poverty - Length of time waiting

Question 385

What are some policies to increase supply?

Answer 385

Additional funding Increased productivity (clinician/management led) - Day case surgery - Skill mix and substitution e.g GPs doing minor procedures Booking patients Use of new providers Financial incentives to reduce waiting times

Question 386

What are some policies to reduce demand?

Answer 386

Demand management: - Incentives for GPs give resources for community based services e.g dermatology - Alternative services - Walk in centres Clinical guidelines that target resources and reduce unnecessary treatment Encourage use of private sector

Question 387

What is the difference between unconditional and conditional max waiting time guarantees?

Answer 387

Unconditional (same for everyone, not able to be moved) - Easy to operationalise - Contradict prioritisation Conditional (on severity, benefit or other) - Difficult to operationalise - Do not contradict prioritisation

Question 388

Why is it important to support patients in their decision-making?

Answer 388

They are generally happier if they can make their own decisions Enables self-determination and respects autonomy Facilitates good doctor-px relationship Professional (GMC) and legal requirement (MCA 2005)

Question 389

What is the main purpose of the mental capacity?

Answer 389

Distinguish between those who should and shouldn’t retain their authority to make decisions regarding aspects of their care.

Question 390

To lack capacity you are unable to...

Answer 390

- Understand - Retain - Weigh up/use - Communicate

Question 391

How do you treat a patient with no capacity?

Answer 391

- Establish each time! - Look for advanced directive - Act in best interests - Take into account beliefs

Question 392

What is the mental capacity act?

Answer 392

- 2005 - Protective framework ensures people who can’t make their own decisions are treated correctly - A person must be assumed to have capacity until proven otherwise - Should be supported in making decision before assuming they can’t make a decision - - Different forms of communication - - Provide info in different formats e.g photo/drawing - - Treat a condition thats impacting capacity, therefore restoring capacity e.g UTI in elderly - Not to be treated as unable to make a decision just because it's unwise decision. - Before a decision is made, should explore less restrictive options for the patient.

Question 393

What is an advanced statement of wishes?

Answer 393

- Wishes and preferences about what care they would like - NOT LEGALLY BINDING - Best interest judgement

Question 394

When is an advanced directive valid?

Answer 394

Patient is 18+ - MCA is for 16+, but under 18’s can’t refuse so an AD requires you to be 18+ Lacks capacity at time of treatment but had capacity at time of making AD. Properly informed patient and statement is clear and applicable to their current situation.

Question 395

What are the pros of advanced directives?

Answer 395

- Respects px autonomy - Encourages forward planning - May lower healthcare costs as people opt for less aggressive treatment - Patient less anxious about unwanted treatment

Question 396

What are the cons of advanced directives?

Answer 396

- Difficult to verify if px opinion has changed since - Difficult to ascertain whether the current circumstances are what the patient foresaw - Possibility of coercion on behalf of px - Possible wrong dx - Can patients imagine future situations sufficiently vividly to make their current decisions adequately informed?

Question 397

What is the epidemiology of falls?

Answer 397

50% have recurrent falls Incidence ^ with age - 35% of 65-79 - 45% of 80-89 - 55% of 90+ These are all per year

Question 398

What are the causes of frequent falls?

Answer 398

Stroke Parkinson's

Question 399

What are the clinical risk factors for hip fractures?

Answer 399

``` Most studies poor quality tbh Psychotropic drugs Stroke Female Age Family history Epilepsy Medications Parkinson’s Certain medical conditions Hypotension Smoking Low body weight ```

Question 400

How can falls be prevented/ decrease risk?

Answer 400

 Increase activity - Diversity of physical activity  Weekly walk for exercise  Strong family networks  Multifactoral falls risk assessment  Multifactoral intervention - Bone hazard assessment - Med review  Education and information

Question 401

How many accidental falls require hospital admission

Answer 401

Over 2 million a year

Question 402

What is the risk of dying after a hip fracture?

Answer 402

20% | Reduced OoL

Question 403

List psychological consequences of falls?

Answer 403

Fear of falling - Further social isolation depression - Self imposed activity restriction ^ dependence and disability --> impacts on carers

Question 404

What is the QALY loss compared to the cost for falls, fractures and fear of falling?

Answer 404

Falls: QALY loss = 30 Cost = £11 mil Fractures: QALY loss = 62 Cost = £50 mil Fear of falling: QALY loss = 597 Cost = £0

Question 405

What are QALYs? Quality adjusted life year

Answer 405

Generic measure of disease burden including both the quality and quantity of life lived and benefits of treatment 1 = 1 year in perfect health 0 = death E.g if illness reduces QALY by 20% and this affects 10 people then 2 QALYs lost Maximising QALYs - Reduce falls and fear of falling produce most benefit to society

Question 406

How can you prevent hip fractures?

Answer 406

Systemic bone protection: - Bisphosphonates used for osteoporosis good evidence, reduced by 30% - Calcium and vit E (lacks evidence) - HRT post-menopause but increased CV risk - Teriparatide (PTH) - remember at low concentration this stimulates osteoblasts Local bone protection: - Hip protectors used but no real evidence

Question 407

How much do hip fractures cost?

Answer 407

- Approx £12k pp - £710 million a year - Osteoporosis most common cause

Question 408

Give examples of complementary therapies and how much they collectively make a year.

Answer 408

- Acupuncture - Chiropractic - Herbal - Homeopathy - Osteopathy - £21m per year

Question 409

How many (%) want CAM on the NHS vs how many who get costs covered?

Answer 409

- 75% want | - 10% get

Question 410

What are some of the barriers to Complementary and Alternative Medicine (CAM) on the NHS?

Answer 410

- Regulating issues - Financial concerns in NHS - Tribalism- different specialties hold onto their patch - Inertial – resistant to change - Mixed evidence of effectiveness - Not all are properly evidence based

Question 411

How many practitioners of acupuncture in the UK are there?

Answer 411

- 2,500 doctors - 5000 physios - 3500 independent Many unregulated

Question 412

Who uses acupuncture?

Answer 412

- MSK px - Fertility/pregnant women - Neurological/chronic pain

Question 413

Why do people turn to CAM?

Answer 413

Effectiveness gap - Area where available treatments aren’t fully effective or satisfactory for (efficacy, acceptability, compliance) so px turn to alternatives.

Question 414

What is the evidence for acupuncture?

Answer 414

Any tx should have evidence base proving it is clinically significant above the placebo effect. No firm conclusions regarding effectiveness for lower back pain, need more high quality trials. Recent evidence (2012) shows effectiveness above placebo effect.

Question 415

What is a criticism of acupuncture?

Answer 415

Effect is too small and not clinically relevant But… - NSAIDS are commonly given and studies have shown the effects to be similar, considering the side effects of NSAIDs, there could be a place for it as an MSK tx?

Question 416

Does NICE recommend acupuncture for osteoarthritis?

Answer 416

No | - Even though it's shown to be above placebo effect and within NICE cost limit.

Question 417

What is chiropractice?

Answer 417

Tx of MSK disorders using spinal/joint adjustment and soft tissue manipulation NICE says to consider it even though it can make back pain worse.

Question 418

Define confounding factor.

Answer 418

Distortion of a relationship between an exposure and outcome due to shared relationship with something else. Either ^ association between exposure and outcome or decreases it.

Question 419

What is an observational study?

Answer 419

Implies no intervention by investigator. An analysis of spontaneously occurring events. Group assignments aren’t random. Used to explore aetiology. Cohort - Start with exposure compare outcomes Case-control - Start with outcome compare exposures

Question 420

Give examples of confounding factors.

Answer 420

Joggers and non-joggers and risk of CHD. Confounding element- joggers eat less pies.

Question 421

How can you address confounding in. design and analysis?

Answer 421

- Restriction - Matching - Stratification - Multiple variable regression

Question 422

What is restriction (exclusion)?

Answer 422

- Possible in design - Limit to people who don’t eat pies - Less data - Difficult when there will be other confounders

Question 423

What is matching?

Answer 423

- Used commonly in case-control studies - Creates a comparison group matched on the possible confounder - i.e match on pie consumption, balance study group so equal numbers of pie and non-pie eaters - Used for strong confounders e.g age and sex - Still need to consider in analysis

Question 424

What is stratification?

Answer 424

- Possible in analysis - Analyse exposure:outcome association in different sub-groups of the confounder - Adjust for confounding if number of variables involved is relatively small - Recombine results to get an adjusted measure of effect - Effectively weighted average of the effect seen in each stratum - Would give an adjusted risk ratio

Question 425

When is it not confounding?

Answer 425

No association between exposure and confounder or no association between confounder and outcome. If the additional variable is on the causal pathway between the exposure and outcome. -- E.g. no of sexual partners HPV +ve --> cervical cancer (HPV positive would not be a confounding factor).

Question 426

What is regression?

Answer 426

Y = a + bx ``` a = intercept b = gradient of slope x = regression coefficient ```

Question 427

What is multiple variable regression?

Answer 427

``` Y = a +bx Y= a + b1x1 Y = a + b1x1 +b2x2 Y = a +b1x1 + b2x2 + b3x3 (e.g jogging, smoking, drinking) ``` Coefficients of these can be used to estimate measures like risk ratios, odds ratios. Compensate for confounding in same way as stratification. Allow for adjustment of estimates for confounding.

Question 428

What should you ask with observational studies?

Answer 428

Have researchers recognised this? Have researchers measured possible confounders? Have researchers taken steps in design or analysis to address confounding? What is the association between exposure and outcome with and without adjustment for other factors If there is a reduced risk in crude risk ratio but no risk ratio when its been adjusted then it means there was a confounding factor. If there is increased risk in both then there wasn’t a confounding factor.

Question 429

What are the 2 approaches to adjustment?

Answer 429

Indirect standardisation | Direct standardisation

Question 430

What is indirect standardisation?

Answer 430

Ratio of observed/expected Standardised mortality ratio Where SMR= 100% population experiences a mortality rate comparable to the standard SMR > 100%- higher than standard SMR < 100% - lower than standard

Question 431

What is direct standardisation?

Answer 431

Weighted average of the stratum specific rates. Weights based on standard population. I.e. you would take the population of the rest of the country and apply the death rate you find to that population and compare it between the two groups you have.

Question 432

How many people are living with dementia and how much does it cost?

Answer 432

Approx 800,000 | £23bn

Question 433

How does dementia patient notice changes?

Answer 433

Forgetfulness Difficulty with names/words Embarrassment in social situations

Question 434

How do family/friends of dementia px notice changes?

Answer 434

Repetitive Forgets social arrangements Deterioration in skills Withdrawal

Question 435

What is a social crisis?

Answer 435

Death of spouse reveals cognitive dysfunction and impairment as person is now unable to cope with day to day life.

Question 436

Who do you tell the dx of dementia to?

Answer 436

Patient so they can make informed decision. Carers need to know to arrange for help. - Carers often don’t want px to know, but wouldn’t they want to know if it was them?!

Question 437

How do patients react to diagnosis of dementia?

Answer 437

Grief response - Anger - Denial - Acceptance and +ve coping strategies- need to plan and reconsider future

Question 438

What determines the response from patients after they receive a diagnosis of demendia

Answer 438

Px insight and stage of illness Type of dementia Previous personality- worrier or someone who laughs things off? - Inform px that you are considering the diagnosis earlier on

Question 439

What is the impact of dx of dementia on carers?

Answer 439

Confirmation of something they suspected Can initiate fear, anger, grief May feel out of depth/ pressure

Question 440

What determines response of carer when px diagnosed with demendia?

Answer 440

- Understanding the illness - Px reaction - Nature of relationship to px

Question 441

What are the benefits of a diagnosis?

Answer 441

Know what you’re dealing with. Access to tx and support services and informative education. Planning for the future eg finances and management of risks e.g driving.

Question 442

What are the types of abuse dementia suffer can encounter?

Answer 442

``` Physical Emotional Neglect Confinement Financial Sexual Willful deprivation Self-neglect ```

Question 443

What does research involve?

Answer 443

- Application of scientific method - Testing of hypotheses - Systematic data collection - Analysis-designed to minimise bias

Question 444

What is the research cycle?

Answer 444

Clinical problem --> Basic research --> Applied research --> Clinical care --> Clinical problem

Question 445

What could the clinical problem be?

Answer 445

Observation, association, prognosis - Person (patient) - Population Clinical vs people important - Why is this a problem, for whom? Priority setting partnerships

Question 446

What constitutes basic research?

Answer 446

Laboratory- based - Biochemistry - Genetics - Physiology - In vitro - Experimental models

Question 447

What constitutes applied (clinical) research?

Answer 447

Question determines type of study - Intervention comparative study - Prognosis cohort study - Diagnosis comparative study - Satisfaction/acceptability survey - Value cost-effectiveness study Most new interventions will have small effect sizes. Small biases and play of chance (random error) can overwhelm effects. Generally treatment effect sizes larger than adverse effect sizes (harm).

Question 448

Where are the evidence into practice gaps?

Answer 448

- Need for knowledge and the discovery of that new knowledge. - Discovery of new knowledge and application of that knowledge. - Clinical application and development of routine clinical actions or policy.

Question 449

What is the implementation gap?

Answer 449

As scientific understanding progresses over time, there is a significant lag behind in the progression of patient care. Gap betwenen scientific undrestanding and patient care

Question 450

What is the variance in number of people receiving best practice for diabetes in primary care?

Answer 450

48%

Question 451

What is the Commission for Quality and Innovation (CQUIN) payment framework?

Answer 451

- Enables commissioners to reward excellence - Links proportion of healthcare providers' income to the achievement of local quality improvement goals - Schemes tailored to needs - stakeholder engagement

Question 452

Name some examples of CQUIN?

Answer 452

National CQUINs 2014-5 - Friends and Family Test – incentivise high performing providers. - Improvement against the NHS Safety Thermometer, particularly pressure ulcers. - Improving dementia and delirium care- “Finding, Assessing, Investigating and Referring (FAIR). - Improving diagnosis in mental health.

Question 453

What are the issues with financial incentives?

Answer 453

Improvements associated with financial gain are achieved to the detriment of a non-incentivized aspect of care. Following the removal of incentives, levels of performance across a range of clinical activities generally remain stable.

Question 454

What are the 4 phases of normal grief?

Answer 454

- Numbness - Yearning/pining and anger - Disorganization and despair - Reorganization

Question 455

What classes as acute grief?

Answer 455

- Somatic or bodily distresses - Preoccupied with images of deceased - Guilt related to deceased or circumstances around their death - Hostility and inability to function

Question 456

What are somatic sensations relating to grief?

Answer 456

Stomach pain Chest pain Weakness

Question 457

List more symptoms of grief.

Answer 457

- Sadness, anger, guilt, anxiety - Somatic sensations - Concentration impairments - Sleep and appetite disturbances

Question 458

What are Worden’s tasks of mourning?

Answer 458

- Accept the reality of the loss - Work through the pain of grief - Adjust to an environment in which that person is missing - Emotionally relocate the deceased and move on with life

Question 459

What is pathological grief?

Answer 459

- Get stuck in one of the phases (normally each stage is 6 months) - Extended grief reaction - Can be in denial for an extended period of time; exhibit mummification (not changing persons room) - Major depressive disorder > 2 months after loss

Question 460

What is the psychological impact of grief?

Answer 460

- Loss of presence – emotional and functional role - Forced to confront own mortality- shattering of immortality impact on their life-stage, younger person more likely to be impacted significantly - Traumatic undermining of the person’s view of the world

Question 461

What can affect the form and characteristics of grief?

Answer 461

Childhood attachment e.g. if primary care giver SO dependent attachment V secure attachment V insecure attachments

Question 462

Define spirituality.

Answer 462

An umbrella term that includes religious/faith frameworks, but is more than that. Meaning of life, purpose, sense of personhood distress arises with feelings of worthlessness and low self-esteem.

Question 463

What is the myth of a neutral therapist?

Answer 463

Idea that psychotherapists will ‘leak’ their personal views regardless of their intention. Will come across in their questioning/direction of questioning.

Question 464

Define palliative care.

Answer 464

The active, holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision of psych, social and spiritual support is paramount.

Question 465

What is the end of life care pathway?

Answer 465

Last 48 hrs of life

Question 466

What is the goal of palliative care?

Answer 466

The goal of palliative care is achievement of the best quality of life for patients and their families.

Question 467

What else is included within the doctor’s role?

Answer 467

Looking after the families not just patient Also financial stuff too Main worries of patients often financial, and worries about family.

Question 468

What is general palliative care?

Answer 468

Core aspect of care for all patients and their families with advanced disease by ALL health professionals. Include - Holistic needs assessment and provision of basic symptom control - Referral to specialist palliative care if appropriate

Question 469

How much in-hospital CPR is inappropriate?

Answer 469

40-50%

Question 470

What is specialist palliative care?

Answer 470

For patients with unresolved symptoms and complex psychosocial issues with complex end of life and bereavement issues. Provided by healthcare professionals for whom palliative care is their core work, who have undergone relevant training.

Question 471

When were the concerns raised over the lack of palliative care knowledge?

Answer 471

1950s

Question 472

What was care extended to include?

Answer 472

Terminal illnesses not just imminently dying. | E.g. heart failure patients

Question 473

Who was Dame Cicely Saunders.

Answer 473

She was a research fellow at St Joseph’s hospice. Developed a systematic approach to pain control - Published and taught what she knew.

Question 474

When did Dame Cicely Saunders open the first modern hospice?

Answer 474

St Christopher’s hospice | 1967

Question 475

How was St. Christopher's hospice funded?

Answer 475

Charitable sector | Usually cancer charities

Question 476

Who are the different team members in generalist palliative care?

Answer 476

- Primary health care team - Nursing home - Secondary care - Social services

Question 477

Who is involved in specialist palliative care services and their roles?

Answer 477

- Clinical nurse specialists- advising on symptom management and psych support. - District nurses - medicines, dressings etc - Specialist physicians in palliative care - Marie Curie nurse - hands on care - Hospices

Question 478

Which parts of the MDT are NHS provided?

Answer 478

- Community clinical nurse specialist - Hospital clinical nurse specialist - Some consultants - Some in-patient units - Macmillan - 3 year pump prime

Question 479

Which parts of the MDT are part of the voluntary sector?

Answer 479

- Hospice services and most in-patient beds (independent charity, Marie Curie, Sue Ryder, other) - Marie Curie nurses - Macmillan

Question 480

What do the hospices, hospitals and community provide?

Answer 480

Hospice: IPU, day hospice, medical clinics, lymphoedema, complementary therapies, education, bereavement services, out-of-hours advice, “hospice at home”, benefits advice. Hospital: medical/nursing advice and support to hospital staff. Community: Macmillan nurse, drop-in centres.

Question 481

Where do most people want to die?

Answer 481

Home not hospital So planning and coordination of care is required

Question 482

What are the services for palliative care outside of hospital?

Answer 482

- Hospice consultant - Community palliative care nurse specialist - Hospice out-of-hours advice phone line - GP - District nurse - Community occupational therapist - Out-of-hours primary care service

Question 483

What are the challenges for the future for caring for dying patients?

Answer 483

- Training, recruitment and retention - Delayed DoH funding, was delayed by 6 years - Inequality of service provision and standards- not forgetting non-cancer conditions - Maintaining a sense of humanity and compassion with the ^^^ in technology and treatment options - Not forgetting that patients are people and that death is not necessarily a medical failure

Question 484

What is the relationship of depression to CVD?

Answer 484

- Unsure/ contentious - Depression --> CVD or CVD --> depression - Post MI and depression: risk of 2nd MI increases and chances of survival drops

Question 485

How does stress affect CVD risk?

Answer 485

- Increases - Despite controlling other factors, it still increases risk - Emotional disturbance and chronic stress have significant impact on SNS and HPA induce various pathophysiology responses that ^ risk of CVD

Question 486

Psychosocial risk factors?

Answer 486

Sociodemographic - Socioeconomic status - Job characteristics e.g. high risk/stress Psychological - Personality e.g. cynical hostility distrusting intentions, worrier - Emotions e.g. anger around MI - Coping behaviors

Question 487

How do psychosocial risk factors affect CVD risk?

Answer 487

Psych risk factors health behaviours --> health and disease outcome. Personality --> tobacco use -> COPD.

Question 488

What is stress a combination of?

Answer 488

Environmental stimulation- real or imaginary Primary appraisal- important to you e.g. goal Secondary appraisal- resources to cope- coping potential or future expeditions Based on appraisal, can feel threatened, challenged

Question 489

What is coping?

Answer 489

Process of trying to manage perceived discrepancies between demands placed on you and your resources to deal Demands match resources challenge Demands outweigh resources --> threat Resources outweigh demands --> boredom

Question 490

How to intervene with stress?

Answer 490

Change appraisal of stress ^ ability to cope or make stress controllable. ^ resources e.g. exams and revision.

Question 491

What is the theme theory?

Answer 491

Where people try and find meaning such as restoring self esteem after a diagnosis.

Question 492

What is the dual process model?

Answer 492

We cope with grief/bad things by carrying out loss orientated and restoration orientated behaviours/tasks.

Question 493

What are loss and restoration orientated behaviours?

Answer 493

LO - grief work, denial all usual grief stuff RO - doing new things/roles/relationships --> stuff that helps you get around it These occur simultaneously

Question 494

What is cardiac neurosis?

Answer 494

Psych disorder where the patient experiences chest pain, breathlessness and palpitations but with no cardiac pathology. Considered form of anxiety disorder.

Question 495

What is the 3 factor model?

Answer 495

Information Motivation Strategy

Question 496

What factors do you need to consider when giving patients information?

Answer 496

Education level and cognitive state Avoiding things and clarify misconceptions

Question 497

Describe motivation in the 3 factor model.

Answer 497

Does px want change - Px trust in tx efficacy - Dr-Px relationship

Question 498

Describe what strategy is in the 3 factor model?

Answer 498

Px can change, need to know - Self-management - Social support – practical, financial - Co-morbidities- depression, anxiety, fear - Planning and agenda setting – don’t give to much in one go, get small goals

Question 499

What are the stages in the transtheoretical model?

Answer 499

Precontemplation - No recognition of need/or interest in change Contemplation - Thinking about changing Preparation - Planning the change Action - Adopt new habits Maintenance - Active practice of new healthier behaviour

Question 500

What is the epidemiology of CHD death in women and men?

Answer 500

Men 29% Women 28%

Question 501

Where is CVD risk highest in the UK?

Answer 501

In deprived areas

Question 502

Why has CVD mortality been falling?

Answer 502

Risk factors improving e.g. fewer smokers, cholesterol better controlled, HTN controlled Treatments medical interventions improved for various cardiac conditions Some risk factors actually increased: obesity, diabetes, physical inactivity

Question 503

What is significant about the social gradient of CVD death?

Answer 503

Improves with higher social class Associated with better health behaviours that come with moving up social ladder

Question 504

What proportions of CVD are for low/middle income countries

Answer 504

75%

Question 505

What is a major influence on CV disease?

Answer 505

Health inequalities Established risk factors are amplified in socially deprived patients

Question 506

Define risk.

Answer 506

Probability of an event in a given time period.

Question 507

Define risk ratio.

Answer 507

Risk ratio = Risk exposed/ Risk unexposed Risk ratio = Risk of CVD smoker/Risk of CVD non smoker Cohort studies

Question 508

What is the population attributable risk?

Answer 508

Proportion of disease in a population attributable to a particular risk factor Risk will increase as exposure prevalence or relative risk increases E.g. how much of CV disease is due to smoking The more who smoke, more risk attributable to smoking in the population Strength of relationship and prevalence of risk exposure are both important

Question 509

What is the prevention paradox?

Answer 509

A preventative measure that brings large benefits to the community but offers little to each participating individual i.e something can have a great impact at a population level may require low risk individuals to change their behaviours To do with prevalence of a certain exposure in the population HYMS definition - Substantial health gain can be achieved if people at low risk of disease act to reduce their risk

Question 510

Give an example of the prevention paradox.

Answer 510

- Cholesterol and CVD - High cholesterol carries CVD risk - Proportion of people with v. high cholesterol is small but population of people with slightly high cholesterol is large - % of CV deaths is high in the slightly high cholesterol groups because of prevalence - In other words, not many people have extremely high cholesterol and because of this the proportion of CVD deaths in this group is low - So people with lower cholesterol who are lower risk would benefit more from intervention due to there being more of them

Question 511

What are the positives and negatives of high-risk strategy?

Answer 511

Positive - Appropriate to individual - Motivated subject and clinician - Cost-effective resource use - Benefit for risk is HIGH Negative - Screening is difficult - Palliative and temporary - Limited potential as not many people

Question 512

What are the positives and negatives of population strategy?

Answer 512

Positive - Large potential as treating so many people Negatives - Population paradox- small perceived individual benefit - Poor motivation and can cause compliance issues - Benefit for risk is LOW

Question 513

What must you weigh up when considering treatment for CVD risk?

Answer 513

Combine risk factors to see as some such as BP have no lower threshold or significant number where risk suddenly increases - E.g. combine: BP, diabetes, renal disease etc. Treating risk is not driven by step difference in the relationship with disease, driven by weighing up cost-benefit: - Cost to individual and population - Absolute harms and absolute benefits

Question 514

What is decision analysis?

Answer 514

- Assists in understanding of a decision task - Divides it into components - Uses decision trees to structure the task - - Uses evidence in the form of probabilities, examine risks associated with each option - - Examines cost with each option - - Suggests most appropriate decision option for that situation - Based on a normative (data from populations) theory of decision making: subjective expected utility theory - Assumes - - Decision process is logical and rational - - A rational decision maker will choose the option to maximise utility (desirability or value attached to a decision outcome)

Question 515

How does decision analysis fit into the evidence-based practice model?

Answer 515

Decisions are based on evidence which is empirical and generated by research Draws on evidence of effectiveness (from RCTs) and prognosis (from RCTs or cohort studies)

Question 516

List the stages in a decision analysis?

Answer 516

- Structure the problem as a decision tree - identifying choices, information (what is and is not known) and preferences - Assess the probability (chance) of every choice branch - Assess (numerically) the utility of every outcome state - Identify the option that maximises expected utility - (possibly) Conduct a sensitivity analysis to explore effect of varying judgements - ‘Toss -up’ if two options have same EU (Dowie, 1993)

Question 517

What do the square and circle nodes mean?

Answer 517

Square node - Decision node - Represents choice between actions Circle node - Chance node - Represents uncertainty - Potential outcome for each decision Triangle nodes - Start point

Question 518

Define utility measures.

Answer 518

Measure of desirability of all possible outcomes in a decision tree Provide numerical value attached to beliefs and feelings Measured on a numerical scale where 0= worst possible outcome and 100 = best possible outcome (or 0 to 1)

Question 519

What is EQ-50?

Answer 519

A utility measure 1. Mobility 2. Looking after myself 3. Doing usual activities 4. Having pain or discomfort 5. Feeling worried, sad or unhappy Plus, an overall rating: How good is your health today? Visual analogue scale from 0 (the worst health I can imagine) to 100 (the best health I can imagine).

Question 520

List 5 things that EQ-50 measures.

Answer 520

1. Mobility 2. Looking after myself 3. Doing usual activities 4. Having pain or discomfort 5. Feeling worried, sad or unhappy

Question 521

Describe QALY

Answer 521

1 year in perfect health = 1 QALY Health states measured against this (e.g. 2 years in health rated as 0.5 of perfect health = 1 QALY). Considers quantity and quality of life. Possibility that living in some health states would be worse than death.

Question 522

What is QALY?

Answer 522

Another utility measure.

Question 523

What is the rating scale?

Answer 523

- Global measure - Easily explained and easy to measure - Not a true utility

Question 524

What is standard gamble?

Answer 524

Grounded in expected utility theory. Assesses utility for a health state by asking how high a risk of death would accept to improve it. Ask to choose between life in given state and a gamble between perfect health and death.

Question 525

What is time trade-off?

Answer 525

Utility assessed by asking how much time would give up to improve it. Choose between set length of life in given health state and shorter length of life in perfect health. Utility given by ratio of shorter to longer life expectancy.

Question 526

How do you calculate expected utility?

Answer 526

Values are placed in decision tree by appropriate outcomes. Expected value for each branch calculated by multiplying utility with probability. Expected values for each branch of tree added together to give EU for each decision option. Depending on nature of values, option with highest / lowest value is the option that should be taken. Start at outcomes and work back to exposure.

Question 527

How do you make the decision?

Answer 527

Carry on working out the values until you reach the square node where you have to make a decision --> choose highest utility value.

Question 528

How do you calculate time trade off?

Answer 528

1 – (number of years willing to give up/ (80-current age))

Question 529

What are the benefits of decision analysis?

Answer 529

- Makes all assumptions in a decision explicit. - Allows examination of the process of making a decision. - Integrates research evidence into the decision process. - Insight gained during process may be more important than the generated numbers. - Can be used for individual decisions, population level decisions and for cost-effectiveness analysis.

Question 530

What are limitations of decision analysis?

Answer 530

Probability estimates: - Required data sets to estimate probability may not exist. - Subjective probability estimates are subject to bias: overconfidence + heuristics (biases). Utility measures: - Individuals may be asked to rate a state of health they have not experienced. - Different techniques will result in different numbers. - Subject to presentation framing effects (e.g. survival / death). - The approach is reductionist.

Question 531

Give some examples of clinical decision support systems.

Answer 531

- Reminder systems - Decision systems for dx and tx - Prescribing - Condition management

Question 532

Give examples of reminder systems.

Answer 532

- Screening - Vaccination - Testing - Medication use - Identification of risky behaviour

Question 533

What is the purpose of diagnostic systems?

Answer 533

Model individual patient data against epidemiological data. Match patient signs and symptoms to database. Provide hypotheses or estimates of probability of different potential diagnoses. - E.g. Ottawa ankle rules (excluding fractures of ankle and midfoot fractures).

Question 534

What is the sensitivity of the Ottawa ankle rules and which studies evaluated it?

Answer 534

Almost 100% Bachmann et al 2003 Dowling et al 2009

Question 535

What is Isabel?

Answer 535

Symptom checker | Provides differential diagnoses

Question 536

What are the benefits of computer support for prescribing?

Answer 536

Reduction in time to achieve therapeutic stabilisation Reduction in risk of toxic drug level Reduction in length of hospital stay Increase in size of initial dose and serum drug concentrations however no change in adverse effects - Doctors have more confidence in prescribing a higher first dose

Question 537

What do computer prescribing softwares do?

Answer 537

Give advice on drug dosage, the drugs themselves Highlight potential drug interactions

Question 538

Why should systems be used for long-term condition management?

Answer 538

- Provide information to assist with monitoring. | - Evaluate number of parameters and make recommendations.

Question 539

List 3 LT conditions.

Answer 539

Diabetes CVD COPD

Question 540

Do computer aids work?

Answer 540

- Yes, even if evidence isn’t that robust Diagnosis - 10 trials - 4/10 found was beneficial Reminders - 16/21 (76%) found benefit Disease management: - 23/40 found improvement in management, 5/17 found improvement in patient outcomes Prescribing: - Single drug prescribing (15/24 found beneficial) - Multiple drug prescribing (4/5 trials found beneficial)

Question 541

List 4 things computer aids are used for.

Answer 541

- Diagnosis - Reminders - Disease management - Prescribing

Question 542

What improves practice when using decision support?

Answer 542

Providing decision support as part of the clinician workflow Providing recommendations for management, (not just patient assessments) Providing decision support when and where decision making was happening Computer-based decision support

Question 543

What can hinder the use of computer systems as aids?

Answer 543

- Earlier negative experience of IT; - Potential harm to doctor-patient relationship; - Obscured responsibilities (loss of autonomy or reasoning); - Reminders increase workload.

Question 544

What is a patient decision aid?

Answer 544

Interventions designed to help people make specific choices among options by providing information about the options and outcomes relevant to that person’s health status.

Question 545

What is the aim of patient decision aids?

Answer 545

Understand probable outcomes of options, by providing information relevant to the decision; Consider the personal value they place on benefits versus harms, by helping clarify preferences; Feel supported in decision making; Move through the steps in making a decision; Participate in deciding about their health care.

Question 546

What is the problem with patient decision aids?

Answer 546

No one can agree on what information should be included/excluded.

Question 547

What did Black et al (2011) find?

Answer 547

Large gap between suggested benefits of eHealth technologies and empirical evidence Some risks in implementation Cost-effectiveness not established

Question 548

Where are oesophageal, gastric and colon cancers most prevalent in the world?

Answer 548

Oesophageal - Middle East and China Gastric - Russia Colon - Western world (US, UK)

Question 549

How much cancer is caused by diet?

Answer 549

Actually unknown and contested Estimated to be approx. 30% Clearly has an impact, but when you try and find the individual component the relationship breaks down

Question 550

How does randomisation work in an RCT?

Answer 550

Block - Recruit people into small blocks - Randomly allocate equal numbers in each block to treatment A or B Stratified - Equal number of people with a characteristic that may affect prognosis - - E.g. breast cancer= same numbers of pre and postmenopausal women - - Keep groups as similar as possible

Question 551

How are people found in case-control studies?

Answer 551

Similar people who have an outcome and a control group who does not. Look back to see exposure status to a risk factor was.

Question 552

What are the problems with case-control studies?

Answer 552

Recall bias, not just peoples memories - People with disease are more likely to recall better as their lives have been impacted by the disease - People without unlikely to make much of an effort Not the same level of information for both groups see relationships that aren’t there Inferior to cohort studies

Question 553

How would recall bias affect diet and cancer analysis?

Answer 553

Possible early impact of disease on diet - If the cancer impacts on diet early on maybe difficult to see if diet caused cancer of if diet was a result of early cancer stages

Question 554

How do you find the participants for a cohort study?

Answer 554

Take a population free of disease and study their exposure to a certain risk factor to see if they develop disease.

Question 555

What are the problems with cohort studies?

Answer 555

Measuring diet in a large group --> variation is massive. Maintaining follow-up over a long time period as cancer takes a long time to develop --> cost-effective?

Question 556

What are the problems with all observational studies?

Answer 556

Bias Confounding factors- certain behaviours associated with types of diet which could impact Hard to establish causal relationship

Question 557

What was the issue with beta carotene?

Answer 557

Cohort studies indicated it had a protective relationship RCT’s starting using supplements in certain high-risk groups RCT’s demonstrated it was the opposite effect and it increased cancer Reduced risk down to confounding factors like increased exercise, reduced smoking and alcohol

Question 558

What is the main problem with measuring diet?

Answer 558

Random error- massive variation, people don’t eat the same and individually it varies a lot.

Question 559

Define homogeneity of exposure?

Answer 559

If you only do studies in same population e.g. only in white males. Likely to have similar environments and diets not able to apply results to population.

Question 560

Give examples of measuring diet.

Answer 560

Food disappearance data Household surveys (what do you buy, who eats what?) Individual - 24hr recall - Food frequency- very bias - Diet diary - Biomarkers (rare)

Question 561

What are the pros of food frequency?

Answer 561

Captures usual diet | Less work to code/complete

Question 562

What are the cons of food frequency?

Answer 562

Don’t record actual diet - Overestimates fruit and veg - Poor measure of energy intake - Less flexible

Question 563

What are the pros of diet diaries?

Answer 563

- Records diet as eaten over - limited period - Better estimate of energy and absolute intake - More flexible

Question 564

What are the cons of diet diaries?

Answer 564

- Requires effort to complete - Expensive to code - Participants make not be accurate/ don’t want people to judge/feel ashamed

Question 565

What is the only proven relationship of cause for hepatic cancer

Answer 565

Aflatoxin contamination

Question 566

What are the only convincing risks found to decrease cancer? And which cancer does it reduce?

Answer 566

- Physical activity - Dietary fibre - Colorectal cancer

Question 567

WHy is 5-a-day a thing?

Answer 567

- Average fruit/veg intake of less than 200g associated with risk of cancer - Possible small benefit beyond 400g a day (80g per portion) - Very little evidence it has an impact

Question 568

What are the key health promotion messages given?

Answer 568

- Increase levels of physical exercise - Don’t put on weight in adulthood - Aim for BMI between 18-25 - Maintain safe levels of alcohol - Increase fruit and vegetable intake to 400g/day - Limit intake of preserved and red meat

Question 569

How much is alcohol expenditure in the UK a year?

Answer 569

£40bn | Lower than many European countries

Question 570

What are the UK’s differences to alcohol consumption compared to europe?

Answer 570

- Spend less - Start earlier - Binge more

Question 571

When was the peak of consumption in the UK?

Answer 571

2008 (affordibility)

Question 572

What is. the % of men and women who have an alcohol use disorder?

Answer 572

38% men 16% women (approx 8mn people)

Question 573

How many men and women are binge drinkers?

Answer 573

21% men 9% women (double recommended daily intake)

Question 574

% of total population who are alcohol dependent?

Answer 574

3. 6% | 1. 1mn people

Question 575

Name some conditions that are attributable to alcohol?

Answer 575

``` Alcoholic liver disease Alcoholic neuropathy Chronic pancreatitis Alcoholic cardiomyopathy Alcoholic gastritis Alcohol related incidents ```

Question 576

Which conditions where alcohol is a risk factor?

Answer 576

Colorectal, mouth, laryngeal, oesophageal cancer

Question 577

Define alcohol attributable fraction (AAF)?

Answer 577

Causal impact estimated from epidemiological studies. Applies to deaths and hospital admissions, estimates alcohol contribution to certain diseases.

Question 578

How many admissions a year are due to alcohol?

Answer 578

- Over 1 million (double 2002/3 because of better recording of cause) - Costing 2.7bn

Question 579

How many deaths were wholly attributable to alcohol in 2013?

Answer 579

- 8000+ | - Decline since 2008

Question 580

In how many domestic violence cases in alcohol consumed?

Answer 580

73% of cases | 50% perpetrators are dependent

Question 581

What is the impact of alcohol on work?

Answer 581

- Poor productivity | - Absences for alcohol related illness/hangover

Question 582

How many family members deal with a problem drinker? How many children are affected?

Answer 582

5 million | 1.3 million children

Question 583

Why is it difficult to implement alcohol policies?

Answer 583

Drinkers vote Ingrained into society - Used for all occasions

Question 584

What are the most effective alcohol policies?

Answer 584

- Price increases (Tax, min price) | - Restricting availability (opening times, age)

Question 585

What are moderately effective policies?

Answer 585

Restricting young people exposure to adverts Treatment identification and brief advice - Difficult at population level

Question 586

What are the least effective policies?

Answer 586

- Drug and alcohol education | - Mass media campaigns

Question 587

What are the key state departments involved in alcohol policy?

Answer 587

- Home office - Department of health - Alcohol industry is highly influential of government

Question 588

When was the first alcohol strategy introduced?

Answer 588

- 2004 | - Alcohol harm reduction strategy for England

Question 589

What happened with the government's strategy in 2012 relating to alcohol?

Answer 589

Switched back to home office control from a joint board that included the alcohol industry who didn’t want to introduce anything that would harm profits Minimum unit price dropped Multi-buy promotion offers not banned Local health bodies able to instigate review of licenses Double fine for selling alcohol to underage people

Question 590

How do hospital staff deal with problem and hazard drinkers?

Answer 590

At least one hospital alcohol health worker to implement screening, detox, interventions and referrals

Question 591

What are some common specialist treatments?

Answer 591

- CBT- most common - Motivational interviewing - Social behaviour and network therapy (SBNT)

Question 592

What is food poisoning/gastroenteritis?

Answer 592

Illness characterised by diarrhoea and vomiting with or without pain

Question 593

What are the microbial causes of gastroenteritis?

Answer 593

- Bacterial e.g. salmonella - Viral e.g. norovirus - Fungal e.g. aspergillus - Protozoal e.g. cryptosporidia

Question 594

What are some of the chemicals that can cause food poisoning?

Answer 594

Heavy metals | Pesticides and herbicides

Question 595

What are some of the toxins that can cause food poisoning?

Answer 595

Bacterial: - Clost. Perfringens - Staph aureus - Clost botulinum Marine: - Scombroid poisoning - Shellfish - Ciguatera

Question 596

How many serotypes of salmonella are pathogenic? And what is the transmission?

Answer 596

All Ingestion of contaminated food or faecal contamination

Question 597

What do you get from salmonella ingestion?

Answer 597

1 of 2 diseases - Enteric fever (s.Typhi) - Enterocolitis (s.enteritidis)

Question 598

What are the symptoms of salmonella ingestion?

Answer 598

Vomiting Diarrhoea Fever

Question 599

What are the pathogenic species of e. coli and what disease does each one cause?

Answer 599

EPEC - enteropathogenic Ecoli - Infantile diarrhoea EAEC - enteroaggregative ecoli - Travellers diarrhoea ETEC - Enterotoxigenic ecoli - Travellers diarrhoea (water and produce in developing countries; vaccine available) EIEC - Enteroinvasive ecoli - Bacillary dystentery, common in developing countries EHEC - enterohaemorrhagic ecoli - Ecoli 0157:H7 - Produces verotoxin - Colonises small intestine

Question 600

How is Ecoli 0157:H7 transmitted and its impacts?

Answer 600

- Rare - Contaminated food and person-person - Kept off school/work for several weeks because of infectiousness - Incubation period = 1-6 days - Haemorrhagic colitis - 5% - haemolytic-uraemic syndrome

Question 601

What is the most common cause of infectious gastroenteritis? And where are outbreaks common?

Answer 601

- Norovirus - Hospitals and nursing homes - Low infective dose – quick spread and high rates - IP: 24-48hrs

Question 602

What is the commonest reported infectious intestinal disease?

Answer 602

- Campylobacter - C.jejuni and c.coli - Low infective dose - Fever, headache, diarrhoea - VOMITING UNCOMMON

Question 603

Define outbreak.

Answer 603

An incident in which two or more people, thought to have a common exposure, experience a similar illness or proven infection.

Question 604

Who do general outbreaks normally affect?

Answer 604

Household members | Institution residents

Question 605

What are the immediate steps to take in an outbreak?

Answer 605

- Who is ill? - How many? - Case finding - What is the cause? - Is proper care being arranged? - What immediate action can be taken?

Question 606

What are the concerns with the safety of food?

Answer 606

- Food borne illnesses - Nutritional adequacy - Environmental contaminants - Pesticides

Question 607

Who does the public health act allow exclusions of work for?

Answer 607

High risk of GI infection spread - Children in nursery/pre-school - People who are involved with food prep - Health and social care staff in contact with vulnerable

Question 608

What does the food safety act state?

Answer 608

- Premises should be registered, licensed and approved - Undergo inspections to ensure they are meeting safety obligations - Offences punishable by fines/imprisonment

Question 609

What does the food safety act 1990 include?

Answer 609

- Drink - Articles of no nutritional value used for human consumption - Chewing gum and similar - Substances used as food ingredients

Question 610

What are some of the offences of the food safety act?

Answer 610

Sale of food rendered unfit for human consumption or contaminated. Sale of any food not of nature or substance or quality demanded by the purchaser. - Horse burgers Display of food for sale with label that is false/misleading.

Question 611

What are the healthcare objectives?

Answer 611

- Equity - improving access to care, but does this create greater equity - Efficiency - Control of expenditure - private or public tax?

Question 612

How much are hospitals overspending by?

Answer 612

£3bn

Question 613

Define efficiency.

Answer 613

Doing the right thing at the right time at the least cost.

Question 614

Define technical efficiency.

Answer 614

- Maximise production of goods or services. - Very good at producing something in high quantities Investing in health care interventions which make the best use of scarce resources

Question 615

Define allocative efficiency.

Answer 615

- Producing what society desires most. - May be technically efficient, but if AE isn’t there then you are producing something that has no need/role so it’s a waste.

Question 616

What is the impact of inefficiency?

Answer 616

Reduces clinician's capacity to meet the health needs of patients. All systems (private and public) are inefficient and have limited resources.

Question 617

Why do we want efficiency?

Answer 617

- Scarce resources - Inefficiency is unethical as it deprives other patients from care they should receive - Ensures maximization of health gains

Question 618

How much of the GDP is spent on healthcare?

Answer 618

9%

Question 619

What is the healthcare expenditure and how much is from the government?

Answer 619

- £136bn (114bn from government). | - NHS primary care is about £170 per capita and £2000 per capita for the NHS as a whole.

Question 620

Ways of household contributions to the healthcare budget?

Answer 620

- General taxation - National insurance - Private insurance - User charges/copayments

Question 621

What can the healthcare budget be spent on?

Answer 621

Salaries Capitation payments (payments per patient) - no control over what you do to patients Fee per item of service - Control of expenditure but you have no idea what it's being spent on e.g extremely inefficient? Unnecessary tests?

Question 622

What are the increasing demands for more funding?

Answer 622

- Multiple morbidities across all age groups- 1 = £700, 7+ = £12k - Ageing population - Tech advances e.g. robotic surgery

Question 623

How much do the private insurers premiums increase by?

Answer 623

2/3 x rate of inflation

Question 624

How are the private and public systems rationed?

Answer 624

``` Private = PRICE Public = NEED ```

Question 625

Ways of controlling expenditure and why they won’t work?

Answer 625

Reduce workforce? --> This is not realistic. Reduce wages and pensions --> GPs have had no pay increase for 10yrs. Increase productivity --> this means doing more for less, one way is to reduce practice variations.

Question 626

What are the funding equity methods in the NHS?

Answer 626

General taxation – income tax or less redistributive VAT Social insurance i.e. national insurance Private insurance – should this get tax subsidies because people are buying their own insurance? User charges – is this a disguised tax or a way to reduce ‘waste’? --> Is it a ‘tax on the ill’?

Question 627

Where is there funding inequality in the UK?

Answer 627

Scotland gets more money per head than other parts. Barnett formula used to divide this money and subsidize parts of the UK.

Question 628

What is the issue with equalizing financing, funding and utilization in healthcare? (input)

Answer 628

May not increase equity in population health status (outcome)

Question 629

How do you measure efficiency?

Answer 629

Cost data Outcome data - SMR- variation in data so not accurate - Quality of life measurement e.g. PROMS – not necessarily sensitive

Question 630

Ways to incentivize more efficient clinical behaviour?

Answer 630

- Penalties - Bonuses - Publish poor rates/performance - Compare colleagues

Question 631

Why do we need economic evaluation?

Answer 631

Assess if changes in resource allocation are efficient Value both inputs and outputs of interventions and policies Allow analysis of 1+ alternative Important because increasing healthcare expenditure needs best outcome for the money e.g. NICE

Question 632

What do clinical and economic evaluations investigate?

Answer 632

Clinical - efficacy and effectiveness Economic - efficiency

Question 633

How do you measure cost?

Answer 633

The value of what you give up - Cost to NHS - NICE perspective, cost of drug and delivery cost - Cost to patient and carers and society in terms of lost working days

Question 634

How do you measure benefit?

Answer 634

Health gain = increase in length + QoL --> NICE perspective Gain for the family = dementia patient being ‘cured’ would take large strain off family Narrow or broad view?

Question 635

What is the cost minimization analysis?

Answer 635

Chooses cheapest option between treatments that have identical outcomes

Question 636

What is cost-effective analysis?

Answer 636

Costs and outcomes are combined into a single measure e.g reduction in blood pressure. Allows comparison between treatments in the same therapeutic area only .

Question 637

What is cost-utility analysis?

Answer 637

Combines multiples outcomes into a single measure (QALY) using QoL instruments e.g. EQ5D. Allows comparisons between alternatives in different therapeutic categories e.g. CV and cancer.

Question 638

What is cost-benefit analysis?

Answer 638

Puts cost and benefit into monetary/numerical terms: | - E.g. how much is the 3 months gained worth to the patient?why

Question 639

When can cost-effectiveness analysis be used?

Answer 639

If the outcome measures are just clinical If other more generic outcome measures are used use cost utility analysis to get QALY (NICE use it)

Question 640

What are the levels of resource allocation decisions?

Answer 640

Macro (societal) level e.g. regarding health funding v education or funding of certain drugs. Micro (clinical) e.g. individual decisions regarding care of individual patients.

Question 641

Argument for age-based rationing to be applied to macro-level resource allocation decisions?

Answer 641

Treatment and care of elderly people is very costly so ‘cost-effective’ argument might require resources elsewhere.

Question 642

Arguments against age-rationing.

Answer 642

Most of the elderly burden relates to costs of illness and incapacity rather than age. Young person with chronic/serious disease could also cost the same amount.

Question 643

Describe the Fair-innings argument.

Answer 643

Alan Williams, 1997 Older people have had a long life already, therefor fairer to divert resources to younger people. Elderly also have a disproportionate share of the available resources allocated to them.

Question 644

Contradiction to Fair-innings argument?

Answer 644

Treating on the basis of need might mean older people don’t receive lower priority Years of life saved shouldn’t matter, the quality of life is more important e.g. QALYs Fairness is not the only thing that matters, other things do too e.g. equal treatment

Question 645

Argument for age-based resource allocation rationing at micro-level?

Answer 645

Age should be relevant because older people are less likely to respond to treatment and have a poorer prognosis in general due to increased complication risk.

Question 646

Argument against age-related resource allocation rationing at a micro-level?

Answer 646

Age alone is not a good predictor of prognosis/complications hence need case-by-case decisions Decisions based on age may be hidden form of discrimination

Question 647

Define age discrimination

Answer 647

Unjustifiable difference in treatment based solely on age.

Question 648

Difference between direct and indirect age discrimination?

Answer 648

Direct = direct difference in treatment based on age, cannot be justified. E.g. treating two people in a comparable situation differently based on age. Indirect = a neutral provision or practice that has harmful repercussions on a person based on their age e.g. a universal hospital discharge policy that disadvantages an older person who needs longer to recover.

Question 649

What is the GMC and laws view on age discrimination?

Answer 649

GMC = must not unfairly discriminate against patients or let views about patient affect decisions. Law = equality act 2010, protects age, race, sex, gender, disability, religion etc.

Question 650

How do you calculate QALY?

Answer 650

Assign a utility value (0-1) to a state of health and then multiply by the number of years expected to live in this state. 0. 5 QALY points x 5 years = 2.5 QALYs 0. 8 QALY points x 5 years= 4.0 QALYs

Question 651

What leads to a utilitarian justification?

Answer 651

QALYs focus on overall likely outcomes of resource allocations.

Question 652

What type of healthcare do you have when the cost per QALY is low?

Answer 652

High priority, efficient healthcare

Question 653

What do you have when you have high cost-per-QALY?

Answer 653

Low priority

Question 654

What are the arguments for QALY-based assessments?

Answer 654

Maximises healthcare based on quality and quantity of life. Considers individual patient level when informing decisions about whether or not to proceed with an invasive procedure based on QALYs they are likely to gain.

Question 655

Objections to QALY-based assessments?

Answer 655

Difficulties in measuring - How do you measure quality or value or life - Who makes these decisions introduce bias (pharm companies v nonprofit) Can seem unjust: - Double jeopardy objection person needing treatment for one condition may lose out if they have a co-morbidity affecting their quality of life - Total cost per QALY for terminal patients going to be higher, but most people value end of life care and don’t think it should be low priority - Can favour life years over individual lives e.g. 1 life with 40 QALYs vs 2 lives with 19 QALYs

Question 656

What is the relationship between age and QALY?

Answer 656

The older you are the fewer QALYs you will gain due to lower life expectancy + co-morbidities. Doesn’t aim for ageism but it is still discriminatory (indirect).

Question 657

Which body appraises medical technologies in £ per QALY?

Answer 657

NICE

Question 658

What does EBDM involve?

Answer 658

 Patient preferences  Available resources  Research evidence  Clinical expertise

Question 659

What are the 4 steps in the approach to smoking cessation?

Answer 659

1. Health education and general information to enhance motivation for quitting (light smokers) 2. Brief advice from a health professional to quit smoking (light smokers) 3. Advice, nicotine replacement, follow-up by a specialist (moderately motivated, medium dependence smokers) 4. Specialised counselling rooms and agencies working with group sessions (high- dependent smokers)

Question 660

Which factors influence infection?

Answer 660

 Infectious agents - Ability to reproduce, survival, ability to spread, infectivity, pathogenicity  Environment - Contamination, other humans, animals, water  Mode of transmission - Droplet, airborne, aerosol, direct consumption, fecal-oral route, blood bourne, sexual contact, zoonosis  Portal of entry - Mouth, nose, ears, genital tract, skin  Host factors - Chronic illness, nutrition, age, immunity, lifestyle (e.g. smoking, drugs etc)

Question 661

What are the most important infectious diseases in the UK?

Answer 661

``` Diptheria, Haemophilus influenza, Measles, Mumps, Poliomyelitis, Rubella, Pneumococcal disease, Tetanus, Whooping cough (pertussis) ```

Question 662

What is the purpose of surveillance?

Answer 662

 Serve as an early warning system for impending public health emergencies  Document the impact of an intervention, or track progress towards specific goals  Monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies

Question 663

Different types of research studies are appropriate for different types of decisions. Give examples of studies/trails/reviews/approaches their use.

Answer 663

Cohort studies – prognosis, cause (prospective) Case-control studies – cause (retrospective) Randomised controlled trials – treatment interventions, benefit and harm, cost-effectiveness Qualitative approaches – patients + practitioner’s perspectives Diagnostic and screening studies – identification Systematic reviews – summary of evidence for a specific question

Question 664

What is an 'explanation why survival following diagnosis is not a good measure of the effect of screening'? ``` Lead time bias Length bias Negative predictive value Prevalence Recall bias Secondary prevention Selection bias Specificity Sensitivity ```

Answer 664

Lead time bias

Question 665

What is length bias?

Answer 665

Length time bias is a form of selection bias, a statistical distortion of results that can lead to incorrect conclusions about the data. Length time bias can occur when the lengths of intervals are analysed by selecting intervals that occupy randomly chosen points in time or space.

Question 666

What is lead time bias?

Answer 666

Lead time is the length of time between the detection of a disease (usually based on new, experimental criteria) and its usual clinical presentation and diagnosis (based on traditional criteria). It is the time between early diagnosis with screening and the time in which diagnosis would have been made without screening. It is an important factor when evaluating the effectiveness of a specific test

Question 667

What is 'the chance of having a negative result given that you do not have the disease'?

Answer 667

Specificity

Question 668

What is 'the chance of having disease if you're test is positive'?

Answer 668

Sensitivity

Question 669

What is 'the proportion of all individuals without disease correctly classified by the screening test' known as? ``` Lead time bias Length bias Negative predictive value Prevalence Recall bias Secondary prevention Selection bias Specificity Sensitivity ```

Answer 669

Specificity

Question 670

What is the 'proportion of individuals with a negative test result who are truly free of disease' known as? ``` Lead time bias Length bias Negative predictive value Prevalence Recall bias Secondary prevention Selection bias Lead time bias Length bias Negative predictive value Prevalence Recall bias Secondary prevention Selection bias ```

Answer 670

Negative predictive value

Question 671

What should systematic reviews have in their inclusion criteria?

Answer 671

 Papers that have not been published (publication bias)  Papers that are not in English

Question 672

What are the benefits of systematic reviews?

Answer 672

 Include ALL the available evidence to answer a question  Include research that is unpublished or published in non-English language journals  Increase the total sample size (and so increase certainty and precision)  Indicate heterogeneity (variation) in findings  Permit sub-group analyses  Permit sensitivity analyses

Question 673

What is study validity and what should you look for?

Answer 673

Study validity is the believability or credibility of the results.  Do these results represent an unbiased estimate of the treatment effect?  Have they been influenced in some systematic fashion to lead to a false conclusion?

Question 674

What are the different types of results?

Answer 674

  Therapy - Look at relative risk reduction, absolute risk reduction, odds ratio, number needed to treat, confidence intervals 
   Diagnosis - Look at sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios 
   Prognosis - Look at how likely the outcomes are over time and how precise the prognostic estimates are (relative risk or odds ratios) 
   Harm/aetiology - Look at relative risk, odds ratio, number needed to harm 


Question 675

What is intention to treat analysis?

Answer 675

All patients who were enrolled and randomly allocated to treatment are included in the analysis and are analysed in the groups to which they were randomised

Question 676

List the different types of research studies and when they are appropriate for decisions.

Answer 676

 Cohort studies - Prognosis, cause  Case-control studies - Cause  Randomised controlled trials - Treatment interventions, benefits and harm, cost effectiveness  Qualitative approaches - Patients and/or practitioners perspectives  Diagnostic and screening studies- Identification  Systematic reviews - Summary of evidence for a specific question

Question 677

List some causes of antibiotic resistance.

Answer 677

* Use in livestock for growth promotion 
 * Releasing antibiotics into the environment during pharmaceutical manufacturing 
 *  Volume of antibiotic prescribes 
 * Missing doses when taking antibiotics 
 * Inappropriate prescribing of antibiotics 


Question 678

How can antibiotic resistance be prevented?

Answer 678

* Using antibiotics only when prescribed by a doctor 
 * Completing the full prescription 
 * Never sharing antibiotics or using leftover prescriptions 
 * Only prescribing antibiotics when they are needed 
 * Using the right antibiotics to treat the illness 


Question 679

Most important infectious diseases in developing countries?

Answer 679

Pneumonia Chronic diarrhoea Malaria HIV/AIDS

Question 680

What were the conclusions and consequences of the Eurocare-II report?

Answer 680

 Despite limitations of the methodology, cancer survival in the UK in the 1980-90s was one of the worst in Europe  Expert advisocalry group formed to the chief medial officer in 1995 which generated the calman-hine report

Question 681

Calman-Hine solutions?

Answer 681

There should be 3 levels of care:  Primary care  Cancer units serving district general hospitals - Treat common cancers, diagnostic procedures, common surgery, non-complex chemo  Cancer centres (populations in excess of 1 million) - Treat rare cancers, radiotherapy, complex chemo Key to managing patients would be the MDT

Question 682

National service framework?

Answer 682

 Set national standards and define service models for a service or care group  Put in place programs to support implementation  Establish performance measures against which progress within agreed timescales would be measured

Question 683

How can consumer protection be improved?

Answer 683

 Appraisal by peers  Revalidation by the GMC  Medical audit as a compulsory part of routine practice and annual job planning  GP and consultant contracts - Increasing transparency in comparative performance in relation to activity, costs, and patient reported outcomes  Transparency and accountability

Question 684

Ulysses arrangement?

Answer 684

Advanced directive for bipolar disorder

Question 685

How many people in the world are infected with TB?

Answer 685

1/3 world population 3 million deaths per year due to TB

Question 686

Factors assocaited with recent increase in prevalance in TB?

Answer 686

 Urban homelessness  IV drug use  Growing neglect of TB control programs  AIDS epidemic

Question 687

What time of year foes TB incidence peak?

Answer 687

Sping/summer

Question 688

What the 2 types of fracture of the neck of the femur? These are common in elderly people. Osteoporosis is the main risk factor for increased fracture risk.

Answer 688

 Extracapsular - The bone outside the joint capsule breaks Tx = Sliding hip screw, intramedullary nail  Intracapsular - The bone within the joint capsule breaks Tx = Internal fixation - Screws, nails, plates and rods

Question 689

How can hip fractures be prevented?

Answer 689

 Fall prevention |  Bone protection - Medication, hip protection

Question 690

What medication is used for secondary prevention of strokes?

Answer 690

 Ischaemic - Clipidogrel, statin, anti-hypertensive, anticoagulant if AF  Haemorrhagic - Anti-hypertensives

Question 691

PROGRESS trail - what did it show?

Answer 691

Reducing BP after stroke reduces risk of stroke recurrence Note - 20% of people with stroke have another in 3 months

Question 692

What is occupational asthma?

Answer 692

Like other types of asthma, it is characterised by airway inflammation, reversible airways obstruction, and bronchospasm, but it is caused by something in the workplace environment

Question 693

List causes of occupational asthma

Answer 693

Bakers, welders, paint sprayers, laboratory workers

Question 694

Occupational causes of COPD?

Answer 694

Coal mining, agriculture, construction, dock workers, brick making

Question 695

What % of lung cancers in men are occupation related?

Answer 695

10%

Question 696

What is silicosis?

Answer 696

Occupational lung disease caused by inhalation of crystalline silica dust, and is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lung.  It is a type of pneumoconiosis.

Question 697

What agency handles claims for compensation for occupational illness in the UK?

Answer 697

Disability Benefits Centre of Benefits Agency (DSS)

Question 698

Most common cause of food poisoning?

Answer 698

Campylobacter (bacterial)

Question 699

What is the concept of the margin?

Answer 699

The incremental change in resources (inputs and their cost) committed to an activity that produces an incremental change in effects (improved patient outcomes)

Question 700

What is cost-benefit analysis?

Answer 700

 Puts cost and benefit into monetary/numerical terms, e.g. how much is the 3 months gained worth to the patient?