Y2 Flashcards
Why is knowing about decision making important?
- 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.
What process do doctors use when making diagnoses?
Hypothetico-deductive reasoning
What must an evidence-based decision include?
- Clinical expertise
- Evidence from research
- Patient preferences
- Available resources
What type of decision is a cohort study appropriate for?
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
What type of decision are case-control studies appropriate for?
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
What type of decision are RCT’s appropriate for?
- Treatment interventions
- Benefit and harm; cost-effectiveness
What type of decision are qualitative studies appropriate for?
- Patient perspective
- Practitioner perspective
What type of decision are diagnostic and screening studies appropriate for?
Identification
What type of decision are systematic reviews appropriate for?
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
What is evidence based medicine?
Process for identifying and using most up-to-date, relevant evidence to inform decisions for individual patient problems.
Why do we need evidence-based medicine?
- 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- Inadequacy of traditional sources of information (out of date textbooks)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
What is the process of EDM?
- 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.
Types of questions?
Difference between the two?
- 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)
What is PICO?
- 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?
After deciding PICO, what is next?
- Identify the best evidence by carrying out a structured search.
- Appraise the identified evidence.
- Integrate the evidence into decision making for the individual patient.
What is the chain of infection?
- Infectious agent
- Host
- Portal of entry
- Mode of transmission
- Reservoir/environment
^ all linked together
Characteristics of an infectious agent/pathogen?
- Ability to reproduce
- Survival (inc. environmental)
- Ability to spread
- Infectivity (ability to cause infection; also colonisation without infection)
- Pathogenicity (severity of the illness)
What is the reservoir/environment?
- ‘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
What is the mode of transmission of an infectious agent?
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
What are the portals of entry of an infectious agent?
- Mouth
- Nose
- Ear
- Genital tract
- Skin (breakdown of barrier)
What are host factors in the transmission of an infectious agent?
- Chronic illness
- Nutrition
- Age (very young, very old)
- Immunity (immune condition; chemo; transplant etc)
- Lifestyle factors (drugs; alcohol; sex; occupation; poverty; leisure activities)
Define outbreak in the context of infection.
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
Define pandemic.
An epidemic occurring over a very wide area.
E.g. crossing international boundaries.
Define surveillance.
- Systemic collection, collation and analysis of data
- Dissemination of the results so appropriate control measures can be taken
- POINT OF CONTROL
Define epidemic.
- 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.
List the common problems of surveilling outbreaks.
- 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
List common healthcare associated infections (HCAI).
- Norovirus (viral gastroenteritis)
- Carbapenemase producing organisms (CPO) - antibiotic resistance
- MERs-CoV - novel or emerging infections where hospital is amplification point
What can increase risk of having healthcare associated infections HCAI?
- 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
How much do healthcare associated infections HCAI cost per year?
Approx £1bn
Different control measures of healthcare associated infections HCAI?
- 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
What is the infection control programme?
- 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
What is global health?
Health of the global population
Improving health and achieving equality in health for all people worldwide
Emphasises transnational health issues, determinants and solutions
What is the motivation for global health?
- Increased awareness of global health disparities.
- Enthusiasm to make a difference across international boundaries.
What is international health defined by?
- Geography (poor nations)
- Problems (infections, water, sanitation)
- Instruments (infection control, Aid, knowledge, medical resources)
- A recipient and donor relationship
What is public health concerned with?
- Prevention
- Equity
- Population-based approaches
- Scientifically validated technical approaches
What is the ‘90/10 gap’ (commission on health research for development - 1990)?
- 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.
List examples of global issues.
- Global warming
- Development, poverty and inequality
- Food and water security
- Wars and security threats
- Migration
What are the relationship/actors/motivation and main instruments for development aid?
- Dependence
- Donors and recipients
- Charity; self interest
- Discretionary allocations
What are major functions of global health?
- 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.
What is the goal of vaccinations?
- To reduce mortality and morbidity from vaccine-preventable infections
- Using vaccination strategy adapted to the epidemiology
What is the strategic aim of vaccinations?
- Selective protection of the vulnerable
- Elimination – through herd immunity
- Eradication
What is the programmatic aim for vaccinations?
- Prevent deaths
- Prevent infection
- Prevent transmission (secondary cases)
- Prevent clinical cases
- Prevent cases in a certain age group
What is eradication of an infectious agent?
- Where no other reservoirs of the infection exist in animals or the environment.
- E.g. smallpox or polio
What is the crucial factor determining the spread of infection?
The number of secondary cases caused by each infectious person
What is an example of a conjugated vaccine and when was it introduced?
- HiB
- Meningitis
- Pneumonia
- 1999
What is the R0 proportionate to?
- 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
What is the basic reproduction number (R0)?
- 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
When can the R0 differ?
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.
What is the effective reproductive number (R)?
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
What is the effective reproduction number (R)?
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)
What makes a population susceptible?
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
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%?
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…
How do mass vaccination programs impact the disease?
- 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
What is the epidemic threshold?
- 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
How do you work out critical proportion susceptible (s*)?
Threshold at R = 1 defines the s* Therefore - R = Ro x s - 1 = Ro x s - S* = 1/Ro
How do you work out the critical vaccination coverage?
H = herd immunity threshold
H = 1 – S*
Measles in the UK:
H = 95% (s* < 5%)
Once > 5%, thn R > 1
What does the critical vaccination coverage depend on?
Vaccine efficacy
What is herd immunity?
- 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
What do you need to consider when choosing the best strategy to implement vaccination programmes?
- Risk of exposure
- Risk of disease and complications
- Susceptibility
- Vaccine features: safety, side-effects, efficacy
- Acceptability/ timing issues
What is the role of the WHO in international vaccination strategy and policy?
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”
Give some examples of international immunisation programmes.
- Expanded programme on Immunisation (EPI)
- Global Polio Eradication Initiative (GPEI)
- Global Alliance for Vaccines and Immunisation (GAVI)
Why is international collaboration necessary for imunisations?
- 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
When was the vaccination law introduced in Britain? Did it work?
1889
No, progressive decline in compliance
The British don’t like being told what to do
Name 3 descriptive methods for collecting research population data?
- Case report
- Case series
- Survey
Name explanatory (analytical) methods for collecting population research data?
Can be observational or experimental.
Observational:
- Cross-sectional
- Cohort
- Case-control
Experimental:
- Laboratory
- Trials (RCT)
Which type of studies seek to make comparisons?
Analytical (explanatory)
- They compare experimental vs. observational
- Inference about exposures and outcomes.
Describe case studies (descriptive).
– 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
Describe case series (descriptive).
– 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
What is the difference between prospective vs. retrospective observational studies?
Has outcome occurred before study starts?
• yes = retrospective
• no = prospective
Advantage of prospective
• data quality
• better able to study incidence
List the advantages and disadvantages of experimental studies.
– 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”
List the advantages of observational studies.
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
What are observational studies classified by?
Subject selection:
– Cross-sectional studies
– Cohort studies
– Case-control studies
What are the limitations of cross-sectional studies?
– 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
What are the pros and cons of cross-sectional studies?
Pros – Representative of population – Potentially efficient – Low cost – Rapid
Cons
– Must verify that risk factor came before
the disease
Describe cross-sectional studies.
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.
Describe cohort studies.
Identify subjects:
- With exposure
- Without exposure
Follow the groups through time to determine if disease develops.
Usually prospective.
List pros and cons of cohort studies.
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
Which observational study is usually retrospective and which is usually prospective?
Case-control = retrospective
Cohort = prospective
Describe case-control studies.
– Identify subjects
• with disease
• without disease
– Compare histories of risk factor (exposure)
• Usually retrospective
When is case-control studies used?
Rare diseases
Relatively quick and inexpensive if quality data is accessible.
List pros and cons of case-control studies.
• Pros: – Rare diseases – Potentially efficient – Low cost – Potential for rapid completion
• Cons:
– Highly susceptible to bias related to
selection of controls
What is the WHO recommended herd immunity threshold for mumps?
90% coverage
Individual rights compared to community health in regards to vaccination?
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
What is bad news?
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
How can bad news be interpreted in psycho-social context?
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
What distancing strategies do clinicians use?
- Avoidance
- Normalization
- Premature reassurance
- False reassurance
- Switching
- Jollying along
What may clinicians worry about when breaking bad news?
- 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.
What 2 mnemonics are there to break bad news?
ABCDE
SPIKES
What is the ABCDE mnemonic?
- Advance preparation
- Build a therapeutic environment/relationship
- Communicate well
- Deal with patient and family reactions
- Encourage and validate emotions
What is the SPIKES mnemonic?
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
What responses to bad news might a patient have?
Basically grief response (can be short or long)
- Anger
- Denial
- Fluctuating mood
- Preoccupation w/ situation
- Agitation/restlessness
- Vegetative signs/symptoms/depression
Define incidence of cancer and incidence rate.
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
Define prevalence.
- Burden of disease in a population
- All ongoing cases of disease
- Prevalence = number of people with disease at any point in time / total population
What is important to consider in cancer epidemiology and why?
- 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
What are the most commonly diagnosed cancers worldwide?
Lungs
Breast
Bowel
Prostate
Give an example of variation of incidence.
Cervical cancer
- 3rd in Africa
- 7th worldwide
What is the most commonly diagnosed cancers in the UK?
Gender specific
- Prostate in men
- Breast in women
Overall/non gender specific
- Lung
Changes in cancer incidence rates in males?
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
Changes in cancer incidence rates in females?
Increases:
- Malignant melanoma
- Thyroid
- Kidney
- Slight in breast because better screening and detection
Decreases:
- Bladder, ovary, oesophageal and stomach
List examples of varying global incidence rates.
- 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
Give explanation for high mortality rates (cancer).
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
How many people in the UK were living with cancer in 2008?
2 million
Why is incidence and survival increasing?
- Ageing population
- Earlier detection
- Improved tx
How do childhood cancers differ to adult ones?
Histopathologically different
Clinically different
- Tend respond to tx
- Better survival rates
How can epidemiology of cancer help?
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
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.
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
How many cancer deaths is tobacco associated with?
50-60%
What is pre-disposition vs susceptibility?
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
What is the difference between primary/secondary/tertiary prevention?
Primary = reduce exposure
Secondary = identify pre-clinical disease and prevent progression
Tertiary = modify outcomes of clinical disease
What is the probability of getting and dying from cancer?
1/3 in lifetime
¼ die from cancer
When was the 5 year cancer survival rates for Britain the worst in Europe?
1980s
1990s
Where was the variation in 5 year survival rates within the UK?
Highest in south
Lowest in north
Causes for poor UK performance?
- 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
When was the Calman-Hine report commissioned?
Why was it commissioned?
1995
Response to evidence of poor UK survival rates in the Eurocare report
What were the Calman-Hine reports main aims?
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
What is the role of the MDT?
- 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
Who is in the MDT?
Medical staff = physician, surgeon, oncologist, radiologist, histopathologist, specialist nurses
Extended = physiotherapist, dietician, palliative care
When was the NHS cancer plan published?
2000
What were the aims of the NHS cancer plan (2000)?
- 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
What did NICE use the NHS cancer plan (2000) for?
Producing improved guidelines for cancer care
Manual of Cancer Standards
How many people would cancer networks serve?
1-2 million people
What were the key areas of action for the cancer reform strategy?
- Prevention
- Earlier dx
- Better tx
- Better outcomes
- Reduced inequalities
What is the philosophical dualism of the body?
’I have a body’ and ‘I am a body’
Who we are and what we are made of
What contributes to body image?
- Complex
- Parents
- Families
- Communities
- Life experience
- Given guidance in various aspects of life so that we can match self-esteem with our abilities
What do we experience as a dual entity?
- Biological bodies
- Social bodies
What is the concept of physical capital?
- Our bodies give us a sense of certain status/ value
- We can ‘read’ bodies
What is sex?
Biological essence/ determinants of gender
What is gender?
Social differences and identity of men and women
How much faster are eating disorders growing in men than women?
Twice as fast
What has contributed to obesity?
Cheaper food
Especially cheaper unhealthy food
What are body dysmorphic disorders?
A mismatch between the inside and the outside
Or
Subjective and objective body image
What are bodies linked to?
Sense of self and self-status
Any threat to body integrity also threatens this
What are the functions of clinical records?
- 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
What are the medical functions of the clinical record?
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
What do you record in a clinical record?
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
When can you remove information?
If it is duplicated, inaccurate
If patient requests it despite reassurance about confidentiality
Describe the medical records in community care.
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
Describe medical records in secondary care.
Largely paper based
Poor quality of computerisation
Why do you use medical records in audit, research and management?
Facilitates clinical governance, risk management and resource management
Hospitals and GPs have individual standards they must reach
What are the rights of access?
- 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
What does critical reflection help you to do?
- 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
Why is critical reflection important?
- Understand and evaluate arguments
- To know when to challenge
- To help make the right decisions
- To be able to explain and justify your decisions
How would you evaluate an argument and know whether or not to agree with them?
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
Why might an argument be invalid?
- 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)
Why might an argument be unsound?
- 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
What should you avoid in an argument?
- 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
If an argument is unsound, is the conclusion false?
- 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.
What are the differences between deductive and inductive arguments?
Inductivereasoning moves from specific instances into a generalized conclusion, while deductivereasoning 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
What are the different disciplines that testing covers?
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
Why do we carry out tests?
- To inform decisions
- To confirm what we believe is wrong with patient
What is a true positive result?
The test result is positive in an individual with the disease.
What is a true negative result?
Test result is negative in an individual wo/ the disease.
What is a false positive result?
False positive - result is positive in person wo/ the disease
What is a false negative result?
False negative - result is negative in individual w/ the disease
What does a good test do?
Maximise the true positive and negatives
Minimise the false positive and negatives
What is sensitivity?
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
What is specificity?
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.
What are predictive values of a test?
- 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
What is the positive predictive value?
Number of true positives/All those who tested positive
Chance of actually having the disease if result comes back positive
What is the negative predictive value?
Number of true negatives/All those who tested negative
The chance of not having the disease if your test is negative
What is D-dimer?
What does its presence suggest?
Degradation product of fibrin
Clotting has occurred
Its presence suggests DVT/PE
What are the PPV and NPV for D-dimer tests?
And what does this mean?
- 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
What does disease prevalence affect? Why?
- 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
What happens to PPV and NPV as prevalence increase?
- PPV increases
- NPV decreases
More people with the disease so chance of picking it up are higher
What happens to PPv and NPV when prevalence decreases?
- 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
Where does disease prevalence change?
- Between primary and secondary care populations different
- Across age groups
- Between countries
What is likelihood ratio?
- 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
What is the LR for positive test results (LR+)?
Chance of testing positive if you have disease/ chance of testing positive if you don’t have disease
What is the LR for negative test results (LR-)?
Chance of testing negative if you have disease/ chance of testing negative if you don’t have disease
What is the significance of LR+ and LR-?
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
What is the pre-test probability?
Chances of disease before test = the disease prevalence in your population
Define screening.
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
What kind of approach is screening?
Population based
Give 4 examples of screening.
- Heel-prick test for congenital diseases
- AAA and ultrasound
- Cervical cancer and smears
- Bowel cancer and FOB
What level of prevention is screening?
- Secondary (most)
- Because detecting early disease allows a potential for early and more effective treatment
Does positive screening = diagnosis?
No
Identifies those who need more dangerous/invasive definitive tests.
What do you need to consider w/ the condition you screen for?
- 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
What do you need to consider w/ the screening test?
- 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
What do you need to consider w/ the treatment after screening?
- 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
What do you need to consider about the screening programme itself?
- 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
Why do screening programmes need to be put through trial first? What should they not do?
- Selection bias
- Length bias
- Lead time bias
Should not assess survival from point of diagnosis
Define selection bias.
The people who come for screening tend to be healthier than those who don’t e.g. ’health screening effect’
Define length bias.
Screening is best at picking up long-lasting and slowly-progressive conditions rather than rapidly-progressing poor prognostic ones
What is sojourn time and how does it link to length bias?
- 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
What are the consequences of length bias?
- 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
Define lead time.
The time between disease detection and clinical symptoms.
Define lead time bias.
- 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
What are the consequences of lead time bias?
Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time
How do you appropriately measure screening effectiveness?
Death rates
Thinking about the condition, why does colorectal cancer have a screening programme and not prostate cancer?
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
Thinking about the test, why does colorectal cancer have a screening programme and not prostate cancer?
Colorectal
- Sensitivity of FOB (80-90%)
- Specificity of FOB (90-98%)
Prostate
- True sensitivity/specificity unknown
Thinking about the treatment, why does colorectal cancer have a screening programme and not prostate cancer?
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?
Thinking about the trials, why does colorectal cancer have a screening programme and not prostate cancer?
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
When thinking about whether to screen for a disease what do you need to assess? (summary)
- Condition
- Test
- Treatment
- Trials
What are the disadvantages of screening?
- 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
Who does/doesn’t benefit from screening?
True positives
- Some will benefit others won’t
True negatives benefit from less anxiety I guess but not much else
What must be considered w/ reproductive ethics?
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
What are the objections to ART?
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
What is the open-future argument?
Children should be ensured a maximally open future i.e widest possible range of opportunities
- Used as basis to terminate embryos with serious disabilities
What type of right do parents have?
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
What are the legal aspects of ART?
What act is it laid out in?
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
Why has the human fertilisation and embryology authority act been criticised?
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
How many ART cycles can 23-39 cycles have for free?
Up to 3
What are other third party interests?
A child born with disability as a result of ART would be a further burden on the state
What is pre-implantation genetic diagnosis (PGD)?
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
What is the pro-life argument?
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
What is the pro-choice argument?
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
What are the problems w/ moral status?
- 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
What are the legal aspects of abortion?
- 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
Are doctors allowed to refuse participation in termination?
- 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
How do children and adult rights differ?
Same
- Involved in decisions and have confidentiality
Differ
- Different decision-making and vulnerability
Why are children of concern?
- 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
What does the GMC state in regards to children?
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
At which age are you presumed competent?
16-17
Must obtain consent
If under 18, you can’t refuse treatments approved by parents or in your best interest
How are decisions made in under 16s?
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
What happens if parents don’t consent to Tx in child’s best interest?
Take them to court
What do best interests comprise of?
- 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
Define parental autonomy.
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.
Pros and cons of making childhood immunisations mandatory?
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
Define the harm principle.
State intervention is justified if it is necessary to prevent greater harm to the public than not intervening.
What do children have a right to be protected from?
- Abuse
- Neglect
- Rights to be involved in own care
Confidentiality in regards to children?
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
When can you provide contraceptive, abortive and STI tx to people under 16 without parental consent?
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.
How many hospital deaths are thought to be avoidable?
6%
List why hospital deaths are thought to be avoidable.
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
Types of medical errors?
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?
What was introduced to reduce MRSA and C.diff?
Reporting and penalties
What are ‘never ever’ events?
- Shouldn’t ever happen
- E.g incorrect blood transfusion
- Get penalties and fines
What are patient reported outcome measures (PROMs)?
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.
Why do we need consumer protection?
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.
What data is available to improve patient safety?
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
What is the hospital level mortality indicator (2012)?
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
What are the different consumer protection agencies?
- 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
What is the role of CQC (care quality commission)?
- 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
What does NICE do?
- Appraise new technologies
- Produce clinical guidelines
- Advise on cost-effective public health interventions
In what way is family structure changing?
Increasingly smaller, single and step-parenting families
What is the social context of pregnancy and childbirth in a professional and ideological context?
Professional
- Doctors Vs midwives who has authority
Ideological
- Nature Vs technology
- Home Vs hospital
- Private Vs public (pure Vs polluted)
Name some inequalities.
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
What is pollution in context of childbirth and pregnancy?
- 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
What is medicalisation?
The process by which events seen as ‘normal’ in life are overtaken by medical practice.
What are some of the medicalisation that have taken place?
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
What was the maternity matters (2009) guideline?
Gives choice to mother about care, continuity of care and safe service
What is the role of midwives?
- 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.
What are the regulations around C sections?
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
What are childhood illnesses in lower income countries mainly caused by?
Infection
Name the major childhood illnesses in high income countries?
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%
What are the major childhood illnesses in low/middle income countries?
- Diarrhoea
- Pneumonia
- Malaria
- HIV/AIDs
- Measles
- Neonatal disorders
How much of A+E paediatric admissions are a result of falls?
50%
What are the most common childhood cancers?
- Leukaemia
- Lymphoma
- CNS and brain
What is included under perinatal?
- Delivery
- Infection
- Congenital
Name acute CNS illnesses?
- Meningitis
- Meningoencephalitis
- Febrile convulsions – URTI with fever, bilateral convulsion need to distinguish from seizure
- Seizure disorder e.g. epilepsy
- Vascular – AVM causing stroke
- Congenital
Name acute respiratory illnesses.
URTI – tonsillitis, croup (parainfluenza), tracheitis (S.Aureus)
LRTI – bronchiolitis (RSV), asthma
Pneumonia – viral, bacterial, atypical
Foreign body inhalation right bronchus
List acute GI illnesses.
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
Significance of UTI under 6 months?
Need ultrasound to look for any structural abnormality e.g horseshoe.
Name common public health measures.
- Seatbelts for accident prevention
- Immunisation
- Antenatal and neonatal checkups and blood spot tests for conditions such as hypothyroidism
Name the common chronic illnesses.
- Asthma
- Epilepsy
- Diabetes
- CF
- IBD
What are the implications of chronic illnesses?
Child = physical, mental, social
Repeated absence at school
Affects parents and siblings
Significant financial for both family and community
National health = provision and planning
How many children are obese and overweight (<5yrs)?
1/6 obese
1/3 overweight
How much of the world’s population live in a country where obesity kills more people than being underweight?
65%
Name the risk factors for childhood obesity.
- Parental obesity
- Gestational diabetes
- Less than 6mths exclusive breastfeeding
- Weaning onto high-fat/sugar foods
- Poor diet + low physical activity
How many deaths under 5 are preventable?
2/3
What is the proportion of all childhood deaths for Africa and South-East Asia?
75%
What were the major causes of death?
- Preterm – 1 million
- Pneumonia
- Diarrhoea
- Malaria
What are the risk factors of death in of under 5s?
- Low birth weight
- Malnutrition
- Non-breastfed children
- Indoor air pollution
What are the preventative measures for death of under 5s?
Vaccination - conjugated vaccine as immature immune system can’t respond to coat adequate nutrition and breastfeeding encouragement
What is the causes of pneumonia in children?
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
What are RF for diarrhoea in children?
- Non-breastfed
- Unsafe water and food
- Poor hygiene
- Malnutrition- zinc in particular
What are Tx for diarrhoea?
- Oral rehydration salts
- Zinc supplements
What prevents diarrhoea in children?
- Exclusive breastfeeding safe water and food
- Adequate sanitation
- Vaccination
What are the causes of diarrhoea in children?
Gastroenteritis:
- Viral (Rotavirus/Norovirus)
- Bacterial
What is the RF for malaria?
- Young children
- Endemic areas
- Lack of vector control (parasite)
- HIV/AIDs
- Drug and insecticide resistance
What is the Tx for malaria?
- Supportive
- Artemisnin-based combo therapy
What is the prevention for malaria?
- Insecticide- treated nets- v.effective
- Indoor residual spraying
- Chemoprophylaxis in endemic regions
What are the causes for malaria?
- Plasmodium parasite
- Most common (P. falciparum)
When is the highest risk for death?
- Neonatal period
- First 28 days
What is the single largest cause of childhood death?
- Preterm birth
- 10% of all births
What are the short term problems for preterm births?
- Infection
- Resp difficulties
- Feeding problems
- Jaundice
What are the long term effects of preterm birth?
- Neuro-disability e.g cerebral palsy
- Chronic lung disease
- Poor growth
How do you minimise health risk to newborns?
Quality care and nutrition during pregnancy + maternal immunisation
Safe delivery
Quality neonatal care:
- immediate breathing
- warmth care
- early breastfeeding
How many children are affected by malnutrition?
20 million globally
More vulnerable to illness and death
Can be treated at home with ready-to-use therapeutic foods
What is included in personal beliefs and values?
- Moral
- Political
- Religious beliefs
- Non-cognitive attitudes e.g. desires and emotions
How can personal beliefs and values impact positively?
Compassion and care
What is the importance of personal beliefs and values in medical practice?
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
What is the problem with personal beliefs?
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
What are the GMC professional expectations?
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.
Can doctors act in accordance with their beliefs?
Yes
So long as it does not negatively interfere with their clinical practice.
What is conscientious objection?
Refusal to perform a legal role or responsibility because of moral or other personal beliefs e.g. in abortion.
What is the problems with conscientious objection (CO)?
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.
What is conscientious objection important?
Could be damaging to force a doctor to do something that they object to and goes against their moral integrity.
Is CO allowed?
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
What does the GMC say about conscientious objection?
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
WHat happens when personal beliefs of patients interferes with your decision making?
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.
Define adverse event.
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.
Define near miss.
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.
What is the frequency of adverse events?
11%
How many adverse events were preventable?
31%
Define side effects.
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.
What are the direct cost of adverse events in additional hospital days?
£2bn
16,000 px claims lodged in 2012/13
20% relate to obstetrics, which account for 80% of cost of all claims
What was the Berwick report?
Mid Staff NHS trust
Focus on mistakes as a learning opportunity for development culture change
What did the Keogh review find?
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.
Why are standard mortality rates not fit for purpose?
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.
Name some alternative approaches to make standard mortality rates (SMR) work.
- 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
Are hospitals with high SMRs providing poor quality care?
- No
- No data to show any relationship between quality of care and SMR rate
What is the prism study?
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.
How many problems/contributory factors are needed for a preventable death - prism study?
3 problems in care
5 contributory factors
What is the swiss cheese model?
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.
Define active failure.
Unsafe acts committed by people in direct contact with patient e.g. giving wrong drug
What are the types of errors?
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.
List the types of violations (intentional rule breaking).
Routine
Situational
Reasoned
Malicious
What is routine violations?
A violation that has become normal behaviour within a peer group.
What is situational violations?
Context dependent e.g. time-pressure, lack of supervision i.e. you know it is wrong but there is no-one to ask.
What is reasoned violations?
Believed to be in patient’s best interest.
What is malicious rule breaking?
Deliberate act intended to harm.
What are latent conditions?
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
What is blame culture?
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
What is normalisation of deviance?
Staff become blind to what is happening and assume practices are normal
So when bad practice becomes normal because everyone is doing it
What type of culture does the NHS need?
- Safety culture (not blame culture1)
- Promotes learning from mistakes
What are some situations associated with increased risk of error?
- Unfamiliarity of task
- Inexperience
- Shortage of time
- Inadequate checking
- Poor procedures
- Poor human equipment interface
Give ways which one can decrease risk of error?
- 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%
Which domains are child development split into?
- Physical
- Cognitive
- Emotional/social
Is child development continuous or discontinuous?
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
Describe continuous child development.
Smooth process/curve, where children accumulate more of same types of skills.
Describe discontinuous child development.
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.
Does child development follow one universal course, or many?
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.
Is development due to nature or nurture?
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.
Is the course of development stable or subject to change?
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.
What are some of the important developments that take place during the first 3-5 years of life?
- Self-regulation
- Communication and language
- Language difficulties
- Establishing relationships with others
- Establishing secure attachment relationships
- Peer relationships
- Social understanding
What are prenatal experiences that can affect child development?
- HIV infection
- Maternal depression during pregnancy
- Drugs etc
What postnatal experiences have an adverse effect on child development?
- Global deprivation
- Postnatal depression
- Quality of infant day care
How does Berk (2000) describe emotional and social development?
- Emotional communication
- Understanding of self
- Ability to manage feelings
- Knowledge about other people
- Interpersonal skills
- Friendships
- Intimate relationships
- Moral reasoning and behaviour
How can you categorise emotions/feelings?
- Positive affect (joy, happy, hope)
- Negative affect (fear, anger, sadness)
What are the 3 predominant functions of emotions?
- Adaptation and survival
- Regulation
- Communication
How do adolescents develop socio-emotionally?
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
Name Erikson’s psychosocial stages (1950).
- 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)
What did Paget (1952) assert?
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.
What are the Piaget stages of cognitive development?
- Sensorimotor period (0-2)
- Preoperational period (2-7)
- Period of concrete operations (7-11)
- Period of formal operations (11+)
What are the 4 terms Piaget uses to explain course of cognitive development?
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.
How does Santrock (1996) describe language development?
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).
What is the theory of multiple intelligences?
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).
Define developmental psychopathology.
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.’
Examples of developmental psychopathology.
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
What are 2 of the most significant experiences a child can miss?
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.
What are indicators of social dysfunction?
- Victimised, ostracised, stigmatised by others -> low self-esteem
- Poor relationships with others
- Social withdrawal
- Inappropriate social behaviour
What are indicators of social well-being?
- Social competence (eg social skills) - linked to +ve self-esteem
- Rewarding personal + social relationships with others
- Communication skills
- Appropriate social behaviour
List indicators of emotional well-being vs dysfunction.
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
What are indicators of cognitive functioning vs dysfunction/impairment?
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
Define labour.
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)
When was the midwives institute formed?
1881
When was the first midwives act set out?
1902
Enshrines normality in childbearing as the midwife’s role, referring to doctors as soon as abnormality occurs
What are the pros of institutionalisation of childbirth?
- 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
What are the cons of institutionalisation of childbirth?
- 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.
What is the medical model of birth?
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)
What is the social model of birth?
- 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
What is the P-value and how do you interpret it?
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
Define research.
A structured activity which is intended to provide new knowledge which is generalisable and intended for wider dissemination.
How is research different to a clinical audit.
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.
Give examples of research atrocities.
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.
What resulted from the nuremberg trials?
Nuremberg code (1947)
Research ethics principles:
- Voluntary consent
- Avoid fill unnecessary physical and mental suffering and injury
- Conducted only by scientifically qualified persons
What is the Helsinki declaration (1964)?
World Medical Association
Requirement that any human research is subject to independent ethical review and oversight by properly convened committee. (Article 13)
What are some of the key research ethics principles?
- Usefulness
- Necessity
- Risks
- Consent
- Confidentiality
- Fairness
- Approval
Define consent.
Permission for something to happen or agreement to do something.
What are some of the ways of facilitating consent?
- Information sheets
- Summary of key points
- Presentation of information
- Opportunity to ask questions
- Time to decide (at least 24 hours)
What should participant information sheets contain?
- 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
What makes consent voluntary?
Not putting pressure on patients or volunteer
Not offering inappropriate (financial) enticements
Not threatening/imposing sanctions
When is consent not required for the use of human tissue?
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.
Can children give consent for the use of their tissues for research?
Yes, but only if Gillick competent.
This includes before death
(should include those responsible for the child though)
Define confidentiality.
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.
What are guidelines for confidentiality?
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.
When is research ethics approval needed?
When there is human parts, tissue, data on lifestyle, housing, working environment, attitude, animals or other organisms.
Why is having ethics approval good?
Minimise harm
Funding
Publishing
Minimise personal responsibility
Protect participants and researcher (adhered to accepted ethical standards ^ recruitment potential!)
Who do you get approval from?
- External body (e.g. NHS)
- Department / subject level committee
What is the most common type of waiting list policy?
Some formof maximum waiting time guarantee.
Why do we need to manage waiting lists?
Limitless demand for health services people can always be more healthy, which creates high demand.
Limited resources – supply of money, staff etc is finite.
How can you ration healthcare?
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?
How do you measure waiting lists?
- Average waiting time
- Who waited longer than x days/months
- Average wait of people on the list
What does a backlog imply?
Need for financial injection.
Why can long waiting lists be good?
Deter frivolous use
Resources constantly fully employed
- Spare capacity waste of money, employment etc.
What do waiting lists improve with?
More doctors
More funds
(not according to Jeremy)
What is activity base remuneration?
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.
What did the 2000-08 policies introduce?
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.
What were the downsides to the implementation of the 2000-08 policies?
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
What are the current challenges in the NHS?
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
What are the consequences for falling off NHS target?
90% expected to be treated within 18 weeks
Breach – reduction of up to 5% of revenues for the speciality in that month
What are alternative possible criteria to manage waiting lists?
- Clinical urgency/severity
- Potential health gain
- Productivity and been less
- Equity waiting lists e.g poverty
- Length of time waiting
What are some policies to increase supply?
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
What are some policies to reduce demand?
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
What is the difference between unconditional and conditional max waiting time guarantees?
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
Why is it important to support patients in their decision-making?
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)
What is the main purpose of the mental capacity?
Distinguish between those who should and shouldn’t retain their authority to make decisions regarding aspects of their care.
To lack capacity you are unable to…
- Understand
- Retain
- Weigh up/use
- Communicate
How do you treat a patient with no capacity?
- Establish each time!
- Look for advanced directive
- Act in best interests
- Take into account beliefs
What is the mental capacity act?
- 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.
What is an advanced statement of wishes?
- Wishes and preferences about what care they would like
- NOT LEGALLY BINDING
- Best interest judgement
When is an advanced directive valid?
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.
What are the pros of advanced directives?
- Respects px autonomy
- Encourages forward planning
- May lower healthcare costs as people opt for less aggressive treatment
- Patient less anxious about unwanted treatment
What are the cons of advanced directives?
- 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?
What is the epidemiology of falls?
50% have recurrent falls
Incidence ^ with age
- 35% of 65-79
- 45% of 80-89
- 55% of 90+
These are all per year
What are the causes of frequent falls?
Stroke
Parkinson’s
What are the clinical risk factors for hip fractures?
Most studies poor quality tbh Psychotropic drugs Stroke Female Age Family history Epilepsy Medications Parkinson’s Certain medical conditions Hypotension Smoking Low body weight
How can falls be prevented/ decrease risk?
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
How many accidental falls require hospital admission
Over 2 million a year
What is the risk of dying after a hip fracture?
20%
Reduced OoL
List psychological consequences of falls?
Fear of falling
- Further social isolation depression
- Self imposed activity restriction
^ dependence and disability –> impacts on carers
What is the QALY loss compared to the cost for falls, fractures and fear of falling?
Falls:
QALY loss = 30
Cost = £11 mil
Fractures:
QALY loss = 62
Cost = £50 mil
Fear of falling:
QALY loss = 597
Cost = £0
What are QALYs?
Quality adjusted life year
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
How can you prevent hip fractures?
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
How much do hip fractures cost?
- Approx £12k pp
- £710 million a year
- Osteoporosis most common cause
Give examples of complementary therapies and how much they collectively make a year.
- Acupuncture
- Chiropractic
- Herbal
- Homeopathy
- Osteopathy
- £21m per year
How many (%) want CAM on the NHS vs how many who get costs covered?
- 75% want
- 10% get
What are some of the barriers to Complementary and Alternative Medicine (CAM) on the NHS?
- 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
How many practitioners of acupuncture in the UK are there?
- 2,500 doctors
- 5000 physios
- 3500 independent
Many unregulated
Who uses acupuncture?
- MSK px
- Fertility/pregnant women
- Neurological/chronic pain
Why do people turn to CAM?
Effectiveness gap
- Area where available treatments aren’t fully effective or satisfactory for (efficacy, acceptability, compliance) so px turn to alternatives.
What is the evidence for acupuncture?
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.
What is a criticism of acupuncture?
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?
Does NICE recommend acupuncture for osteoarthritis?
No
- Even though it’s shown to be above placebo effect and within NICE cost limit.
What is chiropractice?
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.
Define confounding factor.
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.
What is an observational study?
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
Give examples of confounding factors.
Joggers and non-joggers and risk of CHD.
Confounding element- joggers eat less pies.
How can you address confounding in. design and analysis?
- Restriction
- Matching
- Stratification
- Multiple variable regression
What is restriction (exclusion)?
- Possible in design
- Limit to people who don’t eat pies
- Less data
- Difficult when there will be other confounders
What is matching?
- 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
What is stratification?
- 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
When is it not confounding?
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).
What is regression?
Y = a + bx
a = intercept b = gradient of slope x = regression coefficient
What is multiple variable regression?
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.
What should you ask with observational studies?
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.
What are the 2 approaches to adjustment?
Indirect standardisation
Direct standardisation
What is indirect standardisation?
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
What is direct standardisation?
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.
How many people are living with dementia and how much does it cost?
Approx 800,000
£23bn
How does dementia patient notice changes?
Forgetfulness
Difficulty with names/words
Embarrassment in social situations
How do family/friends of dementia px notice changes?
Repetitive
Forgets social arrangements
Deterioration in skills
Withdrawal
What is a social crisis?
Death of spouse reveals cognitive dysfunction and impairment as person is now unable to cope with day to day life.
Who do you tell the dx of dementia to?
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?!
How do patients react to diagnosis of dementia?
Grief response
- Anger
- Denial
- Acceptance and +ve coping strategies- need to plan and reconsider future
What determines the response from patients after they receive a diagnosis of demendia
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
What is the impact of dx of dementia on carers?
Confirmation of something they suspected
Can initiate fear, anger, grief
May feel out of depth/ pressure
What determines response of carer when px diagnosed with demendia?
- Understanding the illness
- Px reaction
- Nature of relationship to px
What are the benefits of a diagnosis?
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.
What are the types of abuse dementia suffer can encounter?
Physical Emotional Neglect Confinement Financial Sexual Willful deprivation Self-neglect
What does research involve?
- Application of scientific method
- Testing of hypotheses
- Systematic data collection
- Analysis-designed to minimise bias
What is the research cycle?
Clinical problem –> Basic research –> Applied research –> Clinical care –> Clinical problem
What could the clinical problem be?
Observation, association, prognosis
- Person (patient)
- Population
Clinical vs people important
- Why is this a problem, for whom?
Priority setting partnerships
What constitutes basic research?
Laboratory- based
- Biochemistry
- Genetics
- Physiology
- In vitro
- Experimental models
What constitutes applied (clinical) research?
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).
Where are the evidence into practice gaps?
- 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.
What is the implementation gap?
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
What is the variance in number of people receiving best practice for diabetes in primary care?
48%
What is the Commission for Quality and Innovation (CQUIN) payment framework?
- 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
Name some examples of CQUIN?
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.
What are the issues with financial incentives?
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.
What are the 4 phases of normal grief?
- Numbness
- Yearning/pining and anger
- Disorganization and despair
- Reorganization
What classes as acute grief?
- Somatic or bodily distresses
- Preoccupied with images of deceased
- Guilt related to deceased or circumstances around their death
- Hostility and inability to function
What are somatic sensations relating to grief?
Stomach pain
Chest pain
Weakness
List more symptoms of grief.
- Sadness, anger, guilt, anxiety
- Somatic sensations
- Concentration impairments
- Sleep and appetite disturbances
What are Worden’s tasks of mourning?
- 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
What is pathological grief?
- 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
What is the psychological impact of grief?
- 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
What can affect the form and characteristics of grief?
Childhood attachment e.g. if primary care giver
SO dependent attachment V secure attachment V insecure attachments
Define spirituality.
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.
What is the myth of a neutral therapist?
Idea that psychotherapists will ‘leak’ their personal views regardless of their intention.
Will come across in their questioning/direction of questioning.
Define palliative care.
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.
What is the end of life care pathway?
Last 48 hrs of life
What is the goal of palliative care?
The goal of palliative care is achievement of the best quality of life for patients and their families.
What else is included within the doctor’s role?
Looking after the families not just patient
Also financial stuff too
Main worries of patients often financial, and worries about family.
What is general palliative care?
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
How much in-hospital CPR is inappropriate?
40-50%
What is specialist palliative care?
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.
When were the concerns raised over the lack of palliative care knowledge?
1950s
What was care extended to include?
Terminal illnesses not just imminently dying.
E.g. heart failure patients
Who was Dame Cicely Saunders.
She was a research fellow at St Joseph’s hospice.
Developed a systematic approach to pain control
- Published and taught what she knew.
When did Dame Cicely Saunders open the first modern hospice?
St Christopher’s hospice
1967
How was St. Christopher’s hospice funded?
Charitable sector
Usually cancer charities
Who are the different team members in generalist palliative care?
- Primary health care team
- Nursing home
- Secondary care
- Social services
Who is involved in specialist palliative care services and their roles?
- 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
Which parts of the MDT are NHS provided?
- Community clinical nurse specialist
- Hospital clinical nurse specialist
- Some consultants
- Some in-patient units
- Macmillan - 3 year pump prime
Which parts of the MDT are part of the voluntary sector?
- Hospice services and most in-patient beds (independent charity, Marie Curie, Sue Ryder, other)
- Marie Curie nurses
- Macmillan
What do the hospices, hospitals and community provide?
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.
Where do most people want to die?
Home not hospital
So planning and coordination of care is required
What are the services for palliative care outside of hospital?
- 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
What are the challenges for the future for caring for dying patients?
- 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
What is the relationship of depression to CVD?
- Unsure/ contentious
- Depression –> CVD or CVD –> depression
- Post MI and depression: risk of 2nd MI increases and chances of survival drops
How does stress affect CVD risk?
- 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
Psychosocial risk factors?
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
How do psychosocial risk factors affect CVD risk?
Psych risk factors health behaviours –> health and disease outcome.
Personality –> tobacco use -> COPD.
What is stress a combination of?
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
What is coping?
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
How to intervene with stress?
Change appraisal of stress ^ ability to cope or make stress controllable.
^ resources e.g. exams and revision.
What is the theme theory?
Where people try and find meaning such as restoring self esteem after a diagnosis.
What is the dual process model?
We cope with grief/bad things by carrying out loss orientated and restoration orientated behaviours/tasks.
What are loss and restoration orientated behaviours?
LO - grief work, denial all usual grief stuff
RO - doing new things/roles/relationships –> stuff that helps you get around it
These occur simultaneously
What is cardiac neurosis?
Psych disorder where the patient experiences chest pain, breathlessness and palpitations but with no cardiac pathology.
Considered form of anxiety disorder.
What is the 3 factor model?
Information
Motivation
Strategy
What factors do you need to consider when giving patients information?
Education level and cognitive state
Avoiding things and clarify misconceptions
Describe motivation in the 3 factor model.
Does px want change
- Px trust in tx efficacy
- Dr-Px relationship
Describe what strategy is in the 3 factor model?
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
What are the stages in the transtheoretical model?
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
What is the epidemiology of CHD death in women and men?
Men 29%
Women 28%
Where is CVD risk highest in the UK?
In deprived areas
Why has CVD mortality been falling?
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
What is significant about the social gradient of CVD death?
Improves with higher social class
Associated with better health behaviours that come with moving up social ladder
What proportions of CVD are for low/middle income countries
75%
What is a major influence on CV disease?
Health inequalities
Established risk factors are amplified in socially deprived patients
Define risk.
Probability of an event in a given time period.
Define risk ratio.
Risk ratio = Risk exposed/ Risk unexposed
Risk ratio = Risk of CVD smoker/Risk of CVD non smoker
Cohort studies
What is the population attributable risk?
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
What is the prevention paradox?
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
Give an example of the prevention paradox.
- 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
What are the positives and negatives of high-risk strategy?
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
What are the positives and negatives of population strategy?
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
What must you weigh up when considering treatment for CVD risk?
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
What is decision analysis?
- 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)
How does decision analysis fit into the evidence-based practice model?
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)
List the stages in a decision analysis?
- 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)
What do the square and circle nodes mean?
Square node
- Decision node
- Represents choice between actions
Circle node
- Chance node
- Represents uncertainty
- Potential outcome for each decision
Triangle nodes
- Start point
Define utility measures.
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)
What is EQ-50?
A utility measure
- Mobility
- Looking after myself
- Doing usual activities
- Having pain or discomfort
- 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).
List 5 things that EQ-50 measures.
- Mobility
- Looking after myself
- Doing usual activities
- Having pain or discomfort
- Feeling worried, sad or unhappy
Describe QALY
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.
What is QALY?
Another utility measure.
What is the rating scale?
- Global measure
- Easily explained and easy to measure
- Not a true utility
What is standard gamble?
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.
What is time trade-off?
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.
How do you calculate expected utility?
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.
How do you make the decision?
Carry on working out the values until you reach the square node where you have to make a decision –> choose highest utility value.
How do you calculate time trade off?
1 – (number of years willing to give up/ (80-current age))
What are the benefits of decision analysis?
- 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.
What are limitations of decision analysis?
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.
Give some examples of clinical decision support systems.
- Reminder systems
- Decision systems for dx and tx
- Prescribing
- Condition management
Give examples of reminder systems.
- Screening
- Vaccination
- Testing
- Medication use
- Identification of risky behaviour
What is the purpose of diagnostic systems?
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).
What is the sensitivity of the Ottawa ankle rules and which studies evaluated it?
Almost 100%
Bachmann et al 2003
Dowling et al 2009
What is Isabel?
Symptom checker
Provides differential diagnoses
What are the benefits of computer support for prescribing?
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
What do computer prescribing softwares do?
Give advice on drug dosage, the drugs themselves
Highlight potential drug interactions
Why should systems be used for long-term condition management?
- Provide information to assist with monitoring.
- Evaluate number of parameters and make recommendations.
List 3 LT conditions.
Diabetes
CVD
COPD
Do computer aids work?
- 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)
List 4 things computer aids are used for.
- Diagnosis
- Reminders
- Disease management
- Prescribing
What improves practice when using decision support?
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
What can hinder the use of computer systems as aids?
- Earlier negative experience of IT;
- Potential harm to doctor-patient relationship;
- Obscured responsibilities (loss of autonomy or reasoning);
- Reminders increase workload.
What is a patient decision aid?
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.
What is the aim of patient decision aids?
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.
What is the problem with patient decision aids?
No one can agree on what information should be included/excluded.
What did Black et al (2011) find?
Large gap between suggested benefits of eHealth technologies and empirical evidence
Some risks in implementation
Cost-effectiveness not established
Where are oesophageal, gastric and colon cancers most prevalent in the world?
Oesophageal - Middle East and China
Gastric - Russia
Colon - Western world (US, UK)
How much cancer is caused by diet?
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
How does randomisation work in an RCT?
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
How are people found in case-control studies?
Similar people who have an outcome and a control group who does not.
Look back to see exposure status to a risk factor was.
What are the problems with case-control studies?
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
How would recall bias affect diet and cancer analysis?
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
How do you find the participants for a cohort study?
Take a population free of disease and study their exposure to a certain risk factor to see if they develop disease.
What are the problems with cohort studies?
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?
What are the problems with all observational studies?
Bias
Confounding factors- certain behaviours associated with types of diet which could impact
Hard to establish causal relationship
What was the issue with beta carotene?
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
What is the main problem with measuring diet?
Random error- massive variation, people don’t eat the same and individually it varies a lot.
Define homogeneity of exposure?
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.
Give examples of measuring diet.
Food disappearance data
Household surveys (what do you buy, who eats what?)
Individual
- 24hr recall
- Food frequency- very bias
- Diet diary
- Biomarkers (rare)
What are the pros of food frequency?
Captures usual diet
Less work to code/complete
What are the cons of food frequency?
Don’t record actual diet
- Overestimates fruit and veg
- Poor measure of energy intake
- Less flexible
What are the pros of diet diaries?
- Records diet as eaten over - limited period
- Better estimate of energy and absolute intake
- More flexible
What are the cons of diet diaries?
- Requires effort to complete
- Expensive to code
- Participants make not be accurate/ don’t want people to judge/feel ashamed
What is the only proven relationship of cause for hepatic cancer
Aflatoxin contamination
What are the only convincing risks found to decrease cancer? And which cancer does it reduce?
- Physical activity
- Dietary fibre
- Colorectal cancer
WHy is 5-a-day a thing?
- 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
What are the key health promotion messages given?
- 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
How much is alcohol expenditure in the UK a year?
£40bn
Lower than many European countries
What are the UK’s differences to alcohol consumption compared to europe?
- Spend less
- Start earlier
- Binge more
When was the peak of consumption in the UK?
2008 (affordibility)
What is. the % of men and women who have an alcohol use disorder?
38% men
16% women
(approx 8mn people)
How many men and women are binge drinkers?
21% men
9% women
(double recommended daily intake)
% of total population who are alcohol dependent?
- 6%
1. 1mn people
Name some conditions that are attributable to alcohol?
Alcoholic liver disease Alcoholic neuropathy Chronic pancreatitis Alcoholic cardiomyopathy Alcoholic gastritis Alcohol related incidents
Which conditions where alcohol is a risk factor?
Colorectal, mouth, laryngeal, oesophageal cancer
Define alcohol attributable fraction (AAF)?
Causal impact estimated from epidemiological studies.
Applies to deaths and hospital admissions, estimates alcohol contribution to certain diseases.
How many admissions a year are due to alcohol?
- Over 1 million (double 2002/3 because of better recording of cause)
- Costing 2.7bn
How many deaths were wholly attributable to alcohol in 2013?
- 8000+
- Decline since 2008
In how many domestic violence cases in alcohol consumed?
73% of cases
50% perpetrators are dependent
What is the impact of alcohol on work?
- Poor productivity
- Absences for alcohol related illness/hangover
How many family members deal with a problem drinker? How many children are affected?
5 million
1.3 million children
Why is it difficult to implement alcohol policies?
Drinkers vote
Ingrained into society
- Used for all occasions
What are the most effective alcohol policies?
- Price increases (Tax, min price)
- Restricting availability (opening times, age)
What are moderately effective policies?
Restricting young people exposure to adverts
Treatment identification and brief advice
- Difficult at population level
What are the least effective policies?
- Drug and alcohol education
- Mass media campaigns
What are the key state departments involved in alcohol policy?
- Home office
- Department of health
- Alcohol industry is highly influential of government
When was the first alcohol strategy introduced?
- 2004
- Alcohol harm reduction strategy for England
What happened with the government’s strategy in 2012 relating to alcohol?
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
How do hospital staff deal with problem and hazard drinkers?
At least one hospital alcohol health worker to implement screening, detox, interventions and referrals
What are some common specialist treatments?
- CBT- most common
- Motivational interviewing
- Social behaviour and network therapy (SBNT)
What is food poisoning/gastroenteritis?
Illness characterised by diarrhoea and vomiting with or without pain
What are the microbial causes of gastroenteritis?
- Bacterial e.g. salmonella
- Viral e.g. norovirus
- Fungal e.g. aspergillus
- Protozoal e.g. cryptosporidia
What are some of the chemicals that can cause food poisoning?
Heavy metals
Pesticides and herbicides
What are some of the toxins that can cause food poisoning?
Bacterial:
- Clost. Perfringens
- Staph aureus
- Clost botulinum
Marine:
- Scombroid poisoning
- Shellfish
- Ciguatera
How many serotypes of salmonella are pathogenic?
And what is the transmission?
All
Ingestion of contaminated food or faecal contamination
What do you get from salmonella ingestion?
1 of 2 diseases
- Enteric fever (s.Typhi)
- Enterocolitis (s.enteritidis)
What are the symptoms of salmonella ingestion?
Vomiting
Diarrhoea
Fever
What are the pathogenic species of e. coli and what disease does each one cause?
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
How is Ecoli 0157:H7 transmitted and its impacts?
- 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
What is the most common cause of infectious gastroenteritis? And where are outbreaks common?
- Norovirus
- Hospitals and nursing homes
- Low infective dose – quick spread and high rates
- IP: 24-48hrs
What is the commonest reported infectious intestinal disease?
- Campylobacter
- C.jejuni and c.coli
- Low infective dose
- Fever, headache, diarrhoea
- VOMITING UNCOMMON
Define outbreak.
An incident in which two or more people, thought to have a common exposure, experience a similar illness or proven infection.
Who do general outbreaks normally affect?
Household members
Institution residents
What are the immediate steps to take in an outbreak?
- Who is ill?
- How many?
- Case finding
- What is the cause?
- Is proper care being arranged?
- What immediate action can be taken?
What are the concerns with the safety of food?
- Food borne illnesses
- Nutritional adequacy
- Environmental contaminants
- Pesticides
Who does the public health act allow exclusions of work for?
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
What does the food safety act state?
- Premises should be registered, licensed and approved
- Undergo inspections to ensure they are meeting safety obligations
- Offences punishable by fines/imprisonment
What does the food safety act 1990 include?
- Drink
- Articles of no nutritional value used for
human consumption - Chewing gum and similar
- Substances used as food ingredients
What are some of the offences of the food safety act?
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.
What are the healthcare objectives?
- Equity - improving access to care, but does this create greater equity
- Efficiency
- Control of expenditure - private or public tax?
How much are hospitals overspending by?
£3bn
Define efficiency.
Doing the right thing at the right time at the least cost.
Define technical efficiency.
- 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
Define allocative efficiency.
- 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.
What is the impact of inefficiency?
Reduces clinician’s capacity to meet the health needs of patients.
All systems (private and public) are inefficient and have limited resources.
Why do we want efficiency?
- Scarce resources
- Inefficiency is unethical as it deprives other patients from care they should receive
- Ensures maximization of health gains
How much of the GDP is spent on healthcare?
9%
What is the healthcare expenditure and how much is from the government?
- £136bn (114bn from government).
- NHS primary care is about £170 per capita and £2000 per capita for the NHS as a whole.
Ways of household contributions to the healthcare budget?
- General taxation
- National insurance
- Private insurance
- User charges/copayments
What can the healthcare budget be spent on?
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?
What are the increasing demands for more funding?
- Multiple morbidities across all age groups- 1 = £700, 7+ = £12k
- Ageing population
- Tech advances e.g. robotic surgery
How much do the private insurers premiums increase by?
2/3 x rate of inflation
How are the private and public systems rationed?
Private = PRICE Public = NEED
Ways of controlling expenditure and why they won’t work?
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.
What are the funding equity methods in the NHS?
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’?
Where is there funding inequality in the UK?
Scotland gets more money per head than other parts.
Barnett formula used to divide this money and subsidize parts of the UK.
What is the issue with equalizing financing, funding and utilization in healthcare? (input)
May not increase equity in population health status (outcome)
How do you measure efficiency?
Cost data
Outcome data
- SMR- variation in data so not accurate
- Quality of life measurement e.g. PROMS – not necessarily sensitive
Ways to incentivize more efficient clinical behaviour?
- Penalties
- Bonuses
- Publish poor rates/performance
- Compare colleagues
Why do we need economic evaluation?
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
What do clinical and economic evaluations investigate?
Clinical - efficacy and effectiveness
Economic - efficiency
How do you measure cost?
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
How do you measure benefit?
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?
What is the cost minimization analysis?
Chooses cheapest option between treatments that have identical outcomes
What is cost-effective analysis?
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 .
What is cost-utility analysis?
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.
What is cost-benefit analysis?
Puts cost and benefit into monetary/numerical terms:
- E.g. how much is the 3 months gained worth to the patient?why
When can cost-effectiveness analysis be used?
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)
What are the levels of resource allocation decisions?
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.
Argument for age-based rationing to be applied to macro-level resource allocation decisions?
Treatment and care of elderly people is very costly so ‘cost-effective’ argument might require resources elsewhere.
Arguments against age-rationing.
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.
Describe the Fair-innings argument.
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.
Contradiction to Fair-innings argument?
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
Argument for age-based resource allocation rationing at micro-level?
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.
Argument against age-related resource allocation rationing at a micro-level?
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
Define age discrimination
Unjustifiable difference in treatment based solely on age.
Difference between direct and indirect age discrimination?
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.
What is the GMC and laws view on age discrimination?
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.
How do you calculate QALY?
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.
- 5 QALY points x 5 years = 2.5 QALYs
- 8 QALY points x 5 years= 4.0 QALYs
What leads to a utilitarian justification?
QALYs focus on overall likely outcomes of resource allocations.
What type of healthcare do you have when the cost per QALY is low?
High priority, efficient healthcare
What do you have when you have high cost-per-QALY?
Low priority
What are the arguments for QALY-based assessments?
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.
Objections to QALY-based assessments?
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
What is the relationship between age and QALY?
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).
Which body appraises medical technologies in £ per QALY?
NICE
What does EBDM involve?
Patient preferences
Available resources
Research evidence
Clinical expertise
What are the 4 steps in the approach to smoking cessation?
- Health education and general information to enhance motivation for quitting (light smokers)
- Brief advice from a health professional to quit smoking (light smokers)
- Advice, nicotine replacement, follow-up by a specialist (moderately motivated,
medium dependence smokers) - Specialised counselling rooms and agencies working with group sessions (high-
dependent smokers)
Which factors influence infection?
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)
What are the most important infectious diseases in the UK?
Diptheria, Haemophilus influenza, Measles, Mumps, Poliomyelitis, Rubella, Pneumococcal disease, Tetanus, Whooping cough (pertussis)
What is the purpose of surveillance?
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
Different types of research studies are appropriate for different types of decisions.
Give examples of studies/trails/reviews/approaches their use.
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
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
Lead time bias
What is length bias?
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.
What is lead time bias?
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
What is ‘the chance of having a negative result given that you do not have the disease’?
Specificity
What is ‘the chance of having disease if you’re test is positive’?
Sensitivity
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
Specificity
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
Negative predictive value
What should systematic reviews have in their inclusion criteria?
Papers that have not been published (publication bias)
Papers that are not in English
What are the benefits of systematic reviews?
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
What is study validity and what should you look for?
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?
What are the different types of results?
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
What is intention to treat analysis?
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
List the different types of research studies and when they are appropriate for decisions.
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
List some causes of antibiotic resistance.
- 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
How can antibiotic resistance be prevented?
- 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
Most important infectious diseases in developing countries?
Pneumonia
Chronic diarrhoea
Malaria
HIV/AIDS
What were the conclusions and consequences of the Eurocare-II report?
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
Calman-Hine solutions?
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
National service framework?
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
How can consumer protection be improved?
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
Ulysses arrangement?
Advanced directive for bipolar disorder
How many people in the world are infected with TB?
1/3 world population
3 million deaths per year due to TB
Factors assocaited with recent increase in prevalance in TB?
Urban homelessness
IV drug use
Growing neglect of TB control programs
AIDS epidemic
What time of year foes TB incidence peak?
Sping/summer
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.
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
How can hip fractures be prevented?
Fall prevention
Bone protection - Medication, hip protection
What medication is used for secondary prevention of strokes?
Ischaemic - Clipidogrel, statin, anti-hypertensive, anticoagulant if AF
Haemorrhagic - Anti-hypertensives
PROGRESS trail - what did it show?
Reducing BP after stroke reduces risk of stroke recurrence
Note - 20% of people with stroke have another in 3 months
What is occupational asthma?
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
List causes of occupational asthma
Bakers, welders, paint sprayers, laboratory workers
Occupational causes of COPD?
Coal mining, agriculture, construction, dock workers, brick making
What % of lung cancers in men are occupation related?
10%
What is silicosis?
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.
What agency handles claims for compensation for occupational illness in the UK?
Disability Benefits Centre of Benefits Agency (DSS)
Most common cause of food poisoning?
Campylobacter (bacterial)
What is the concept of the margin?
The incremental change in resources (inputs and their cost) committed to an activity that produces an incremental change in effects (improved patient outcomes)
What is cost-benefit analysis?
Puts cost and benefit into monetary/numerical terms, e.g. how much is the 3 months gained worth to the patient?
