Year 2 Health and Society 3 Flashcards

Question

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

Answer 1

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

Answer 2

- Regulation of the quality of imported food, medicines, manufactured goods, and inputs
- Getting timely access to information about the global spread of infectious disease
- Procurements of sufficient vaccine and drug supplies in a pandemic
- Ensuring a sufficient corps of well-trained health personnel

Answer 3

- Help spread infectious diseases
- Transmission of behaviour and culture increases risk of non-communicable diseases
- May introduce a disease to a new population - widespread and deadly effects
- More in contact with animals - increase in animal diseases (zoonosis)
- Migrants may bring diseases to countries that have not been exposed

Answer 4

- All the physical, chemical and biological factors external to a person, and all the related behaviours
- Environmental health consists of preventing or controlling disease, injury, and disability related to the interactions between people and their environment

Answer 5

Sudden increase in occurrences of a disease in a community, which has never experienced the disease before or when causes of the disease occur in numbers greater than expected in a defined area

Answer 6

Occurrence of a group of illnesses of similar nature and derived from a common source, in excess of what would be normally expected in a community or region

Answer 7

Worldwide epidemic (outbreak -> epidemic -> pandemic)

Answer 8

- Insure developing countries against the threat of a pandemic
- Funds and international responders sent to country with outbreak to reduce human suffering
- Development of vaccines
- Fast, early, planned response means less spread
- Monitor disease to prevent future outbreaks

Answer 9

- Providing leadership on matters critical to health and engaging in partnerships where joint action is needed
- Shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge
- Setting norms and standards and promoting and monitoring their implementation
- Articulating ethical and evidence-based policy options
- Providing technical support, catalysing change, and building sustainable institutional capacity
- Monitoring the health situation and assessing health trends

Answer 10

- Introduction of blood donor and product screening
- Promotion and distribution of condoms at affordable prices
- Peer education for high risk groups e.g. sex workers
- Promotion of safer sexual behaviour at the population level
- Diagnosis and treatment of STDs
- HIV voluntary counselling and testing

Answer 11

- Economics - many developing countries can only spend a few dollars per annum per capita on healthcare
- Priorities - 'developed world academic' analyses of cost-effectiveness may not reflect the developing world realities
- Setting - countries where true reductions in incidence and prevalence have occurred (e.g. Uganda) may be characterised by openness in political leadership towards HIV/AIDS and other cultural factors

Answer 12

- Africa struggles against debt, trade restrictions and inadequate aid provisions
- Global fund în under-resourced
- US politics are retrogressive and harmful

Answer 13

- To reduce mortality and morbidity from vaccine preventable infections
- To prevent outbreaks and epidemics
- To contain an infection in a population
- To reduce the number of infections
- To interrupt transmission to humans
- To generate herd immunity
- To eradicate an infectious agent

Answer 14

- Clean drinking water
- Vaccination

Answer 15

- Disease burden
- Risk of exposure to the disease
- Age, health status, vaccination history
- Special risk factors
- Reactions to previous vaccine doses, allergies
- Risk of infecting others
- Cost
- Other ways of controlling the disease
- Impact on public perception

Answer 16

- Where no other reservoirs of the infection exist in animals or environment
- Where consequences of infection are very high
- Where scientific and political prioritisation exists

Answer 17

- Smallpox
- Polio

Answer 18

- Level of immunity in the population which protects the whole population
- Herd immunity only applies to diseases which are passes from person to person
- Provides indirect protection to unvaccinated as well as direct effect to the vaccinated
- A disease can therefore be eradicated even if some people remain susceptible

Answer 19

- Basic reproduction rate
- The average number of individuals directly infected by an infectious case during the infectious period, in a totally susceptible population (number of secondary cases following introduction of infection)

Answer 20

- The rate of contacts in the host population
- The probability of infection being transmitted during contact
- The duration of infectiousness

Answer 21

Estimates the average number of secondary cases per infectious case in a population made up of both susceptible and non-susceptible hosts

Answer 22

R = R0x (x is the fraction of the host population which is susceptible e.g. half population is 0.5)
R >1 = number of cases increases
R <1 = number of cases decreases, needs to be maintained for elimination
R =1 = epidemic threshold

Answer 23

H = (R0 -1) / R0

Answer 24

- Any person who is not immune to a particular pathogen is said to be susceptible
- A person may be susceptible because they have never encountered the infection or the vaccine against it before
- A person may be susceptible because they are unable to mount an immune response
- A person may be susceptible because vaccination is contraindicated for them

Answer 25

- 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

Answer 26

- Expanded programme on immunisation (EPI)
- Global polio eradication initiative (GPEI)
- Global alliance for vaccines and immunisation (GAVI)

Answer 27

- Who - to protect the vulnerable, contain outbreak, eradicate disease
- How - pilots, phased introduction, global vaccination
- When - greatest impact on disease burden

Answer 28

- Conversation between patient and their health care professional to reach a health care choice together
- Important when - there is more than one reasonable option, no one option has a clear advantage, the possible benefits/harms of each option affect patients differently

Answer 29

- Can save lives
- Ingredients are safe in the amount used
- Adverse reactions are rare
- Herd immunity
- Save children and parents time and money
- Protect future generations
- Eradication of diseases
- Economic benefits for society

Answer 30

- Can cause serious and sometimes fatal side effects
- Contain harmful ingredients
- Government should not intervene in personal medical choices
- Can contain ingredients some people object to e.g. chicken eggs
- Unnatural
- Pharmaceutical companies main goal is to make profit
- Some diseases that vaccines target are relatively harmless in many cases e.g. rotavirus

Answer 31

- Lifestyle
- Perception of health
- Beliefs about childhood diseases
- Risk perception of the diseases
- Perceptions about vaccine effectiveness and vaccine components
- Trust in institution

Answer 32

- For the individual - protection by 'herd immunity' may be safest option as avoids risk of vaccine
- For the community - avoidance of vaccination leads to reduced coverage so diminishes herd immunity

Answer 33

- NHS fitfortravel
- The National Travel Health Network and Centre (NaTHNaC)

Answer 34

- Free - diphtheria, polio, tetanus, typhoid, hepatitis A, cholera
- Private - hepatitis B, Japanese encephalitis, meningitis, rabies, TB, yellow fever

Answer 35

- The country or countries you're visiting
- When you're travelling
- Where you're staying
- How long you'll be staying
- Your age and health
- What you'll be doing during stay
- If you're working as an aid worker
- If you're working in a medical setting
- If you're contact with animals

Answer 36

1. Breast/prostate
2. Lung
3. Bowel
4. Melanoma
5. Non-Hodgkin lymphoma

Answer 37

1. Lung
2. Bowel
3. Prostate/breast
4. Pancreas
5. Oesophagus

Answer 38

Leukaemias

Answer 39

Brain, CNS and intracranial tumours

Answer 40

Mortality is higher in UK (29%)

Answer 41

- Prevention - legal and lifestyle changes, vaccinations
- Screening - early detection and diagnosis
- Disease management - improving treatments and quality of life

Answer 42

Bad/difficult news is defined as any news that drastically and negatively alters the patient's (or their relatives) view of his or her future

Answer 43

- Institutionalised beliefs
- Personality types
- Gender
- Culture/race
- Religion
- Patients knowledge
- Relatives

Answer 44

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

Answer 45

A - Advanced preparation
B - Building a relationship
C - Communicate well
D - Deal with patient reactions
E - Encourage and validate emotions

Answer 46

S - Setting up
P - Perception
I - Invitation
K - Knowledge
E - Emotions
S - Strategy and summary

Answer 47

- Grief
- Distress
- Denial
- Anger
- Agitation/restlessness

Answer 48

- Change in roles
- Change in responsibilities
- Change in physical needs
- Change in emotional needs
- Change in sexuality and intimacy
- Change in future plans

Answer 49

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

Answer 50

(The Calman-Hine report examined cancer services in the UK, and proposed a restructuring of cancer services to achieve 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

Answer 51

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

Answer 52

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

Answer 53

- Save more lives
- Ensure people with cancer get the right professional support, care and treatments
- Tackle the inequalities in health e.g. unskilled workers are 2x more likely to die from cancer as professionals
- Build for the future - investment in cancer workforce, strong research, preparation for the genetics revolution

NHS plan followed by several improving outcomes guidance (NICE) which relate to the organisation of services for a particular cancer.

- 2000 manual of cancer - >300 standards relating to the delivery of cancer treatment including provisions of chemotherapy, radiotherapy, etc.
- 2004 manual of cancer (manual of quality measures) - >900 new measures

Answer 54

- Prevention - smoking, obesity, alcohol, etc.
- Screening - diagnosing cancer earlier
- Ensuring better treatment - reduced waiting times, increase in radiotherapy capacity, new cancer drugs be referred to NICE, chemotherapy audits
- Living with and beyond cancer - National cancer survivorship initiative
- Reducing cancer inequalities
- Delivering care in the most appropriate setting - locally where possible, services should be centralised where necessary

Answer 55

- Cervical
- Breast
- Bowel

Answer 56

Partnership with cancer charities, clinicians and patients, considered a range of approaches to improving services and support available for cancer survivors

Answer 57

- Prevention and early diagnosis - focus on lifestyle factors, screening, diagnostic tests
- Quality of life and patient experience - patient experience surveys, more 1:1 support roles, risky stratified pathway of care, following assessment and care planning
- Better treatments - cancer drugs fund, reducing variation in radiotherapy, reaffirmed MDTs and national audits
- Reducing inequalities

Answer 58

- White cancer patients report a more positive experience than other ethnic groups
- Younger people are the least positive about their experience, particularly around understanding completely what was wrong with them
- Men are generally more positive about their care than women, particularly around staff and staff working together
- Non-heterosexual patients reported less positive experience, especially in relation to communication and being treated with respect and dignity
- People with rarer forms of cancer in general reported a poorer experience of their treatment and care then people with more common forms of cancer

Answer 59

- Spearhead a radical upgrade in prevention and public health
- Drive a national ambition to achieve earlier diagnosis
- Establish patient experiences being on a par with clinical effectiveness and safety
- Transform our approach to support people living with and beyond cancer
- Make the necessary investments required to deliver a modern high-quality service
- Overhaul process for commissioning, accountability and provision

Answer 60

- Perceptions, thoughts, and behaviours related to one's appearance
- The body is a bearer of values and a means of representing our identity to others - it shows who we are to others

Answer 61

- Chronic illness leads to a loss of confidence in the body
- From this follows a loss of confidence in social interaction or self-identify

Answer 62

- Scars
- Prosthetic device - e.g. leg
- Mastectomy
- Impact on sexuality - function, pain, appearance
- Stoma
- Hair loss
- Weight loss/weight gain

Answer 63

- An important site for individual and group identity
- A way of 'doing gender' - a symbol of felinity? hair loss not so bad for men
- Stigma - patients have some choices as to whether they will be stigmatised
- Patient control of their status as sick - can be managed through 'normal' appearance (wigs, beanies, scarves)

Answer 64

- Support patient care
- Improve future patient care
- Social purposes at the request of patients
- Medico-legal document

Answer 65

- Presenting symptoms and reasons for seeking health care
- Relevant clinical findings
- Diagnosis and important differentials
- Options for care and treatment
- Risk and benefits of care and treatment
- Decisions about care and treatment
- Action taken and outcomes

Answer 66

- Paper - continuous, portable, writer identified, legibility issues, must be dated and signed
- Electronic - problem orientated, searchable, structured, safer prescribing, clinical decision support software

Answer 67

- Support clinical audit
- Facilitates clinical governance
- Facilitates risk management
- Support clinical research

Answer 68

Legal obligation which is imposed on an individual requiring adherence to a standard of reasonable care while performing any acts that could foreseeable harm others

Answer 69

- Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances
- You have to make decisions that adheres to your duty of care as a doctor and could not be considered negligent

Answer 70

- Beneficence - duty to do good
- Non-maleficence - duty to cause no harm
- Autonomy - patient has the right to make their own decision
Justice - fair, equitable treatment for all

Answer 71

- Consequentialism/utilitarianism - the correct moral response is related to the outcome or consequence of the act
- Deontology - places value on the intentions of the individual and focuses on rules, obligations and duties
- Virtue ethics - right living is derived from the moral character of the agent

Answer 72

1. Get clear on the logical form of the argument
2. Query - valid and sound

Answer 73

- 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

Answer 74

- Argument is invalid
- Argument is valid but one or more premise is false - makes a false/controversial moral/empirical claim
- An unsound argument doesn't mean there will be an unsound conclusion

Answer 75

- Straw man fallacy - simply ignoring the person's actual position and substituting it for a distorted, exaggerated or misrepresented version of that position
- Ab hominem - directed against a person rather than the position they are maintaining
- Appealing to emotion
- Begging the question
- Argument from fallacy - conclusion must be false because the premises are false (not necessarily)

Answer 76

- Seek to support a moral claim of some kind
- Argument need not succeed but to be an argument it must at least provide supporting reasons for the claim in question

Answer 77

- Purely logic
- "This means this, therefore this means this"

Answer 78

Making an argument based on observation, more probable conclusions (seeing is believing but you may not have seen everything)

Answer 79

- Modern management of cancer - involves many disciplines, surgical and non-surgical, oncology
- Allied health professionals e.g. nurses, physiotherapists, speech therapists, etc.
- Delivery of cancer care is often fragmented over several hospital sites - need to streamline and co-ordinate various components of care
- Probably better outcomes for patients managed in MDTs

Answer 80

Core (medical staff):
- Physicians
- Surgeons
- Oncologist
- Radiologist
- Histopathologist
- Specialist nurses
- MDT coordinator

Extended:
- Physiotherapist
- Dietician
- Palliative care
- Chaplin

Answer 81

- Discuss every new diagnosis of cancer within their site
- Decide on a management plan for every patient
- Inform primary care of that plan
- Designate a key worker for that patient
- Develop referral, diagnosis and treatment guidelines for their tumour sites
- Audit

Answer 82

- True positives
- Measures the proportion of positives that are correctly identified

Answer 83

Sensitivity = true positives / (true positives + false negatives)

Answer 84

- True negatives
- Measures the proportion of negatives that are correctly identified

Answer 85

Specificity = true negatives / (true negatives + false positives)

Answer 86

Any kind of medical test performed to aid in the diagnosis or detection of disease

Answer 87

- Diagnosis
- Monitoring
- Screening
- Prognosis

Answer 88

The importance of a diagnostic accuracy testing is directly proportional to the tests potential to cause patient consequences and harm

Answer 89

Test indicates disease when there is disease

Answer 90

Test indicates no disease when there is no disease

Answer 91

Test indicates disease when there is no disease

Answer 92

Test indicates no disease when there is disease

Answer 93

The probability that subjects with a positive screening test truly have the disease

Answer 94

The probability that subject with a negative screening test truly don't have the disease

Answer 95

The likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that the same result would be expected in a patient without the target disorder

Answer 96

Systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder

Answer 97

- Opportunities for primary prevention are limited
- Opportunities for treatment are limited
- Screening gives potential for early and more effective treatment

Answer 98

- Cancer - colorectal cancer, breast cancer, cervical cancer
- PPD test - tuberculosis
- Prenatal tests - foetal abnormalities
- Newborn bloodspot test - PKU, cystic fibrosis, etc.
- Ophthalmoscopy or digital photography and image grading - diabetic retinopathy
- Ultrasound scan - abdominal aortic aneurysm
- Screening for metabolic syndrome
- Screening for potential hearing loss in newborns

Answer 99

- Cost and use of medical resources on a majority of people who do not need treatment
- Adverse effects of screening procedure - stress, anxiety, discomfort, radiation exposure
- Stress and anxiety caused by a false positive result
- Unnecessary investigation and treatment of false positive results
- Stress and anxiety caused by prolonging knowledge of an illness without any improvement in outcome
- A false sense of security caused by false negatives, which may delay final diagnosis

Answer 100

Pros - early detection of disease means the risk of death or illness can be reduced for some people

Cons - Some people get tests, diagnosis ad treatment with no benefit; some people get ill or die despite a negative screening test

Answer 101

- Condition - important? epidemiology, natural history of condition, detectable risk factor, latent period, cost-effective
- Test - simple, safe, precise, validated, cut-off agreed, acceptable
- Treatment - effective evidence based treatment
- Programme - RCT evidence of reduction in mortality or morbidity, benefit outweigh harm, opportunity cost, quality assurance

Answer 102

- The duration of a disease before clinical symptoms become apparent but during which it is detectable by a screening test
- Its clinical relevance is that it represents the duration of the temporal window of opportunity for early detection
- Length of sojourn time = short - rapidly progressing disease, poorer prognosis
- Length of sojourn time = long - better prognosis

Answer 103

Overestimation of survival duration among screening-detected cases by the relative excess of slowly progressing cases

Answer 104

- Diseases with a longer sojourn time are 'easier to catch' in the screening net
- On average, individuals with diseases detected through screening 'automatically' have a better prognosis than people who present with symptoms/signs
- If we simply compare individuals who choose to be screened with those who don't we get a distorted picture

Answer 105

Overestimation of survival duration among screen-detected cases (relative to those detected by signs and symptoms) when survival is measured from diagnosis

Answer 106

- Survival is inevitably longer following diagnosis through screening because of the 'extra' lead time
- Because of this the appropriate measure of effectiveness is deaths prevented, not survival

Answer 107

- Overestimation of survival duration among screen-detected cases caused by inclusion of pseudo disease - subclinical disease that would not become overt before the patient dies of other causes
- Occurs when screen-detected cancers are either non-growing or so slow-growing that they never would cause medical problems

Answer 108

- Prostate-specific antigen (PSA) - protein produced by cells of the prostate gland
- Elevated in - prostate cancer, BPH, prostatitis, UTI, exercise

Answer 109

- Can help detect tumours with no symptoms
- Allows estimation of prostate size and stage
- Helps doctor predict response to treatment
- Can be used to monitor men who are at increased risk

Answer 110

- Early detection may not reduce the chance of dying from prostate cancer
- Over-diagnosis -> over-treatment
- May give false-positive - other conditions can increase PSA, not specific enough
- May give false-negative

Answer 111

- Distress
- Embarrassment
- Inconvenience
- Threat to self esteem
- Loss of personal control
- Desire for normalisation
- Loss of interest in sex
- Difficulty sleeping (especially with nocturia)

Answer 112

- Regular hospital admissions
- Restriction of leisure time
- May have to give up job
- Increased dependence on dialysis
- Uncertainness about the future
- Fatigue
- Limitations of liquids and foods
- Disrupts family and friend relationships
- Depression
- Lower self-esteem

Answer 113

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

Answer 114

- The loss of other alternative when one alternative is chosen
- The amount of money that is alienated by choosing to use it for one project than another

Answer 115

How we distribute resources the are finite in a fair way

Answer 116

- QALY calculation
- Waiting list
- Likelihood of complying with treatment
- Lifestyle choices of patient
- Ability to pay

Answer 117

Pledge of agreement to not divulge or disclose information about patients to others

Answer 118

- Improves trust between patient and doctor
- Respects autonomy
- Prevents patient harm
- Virtuous
- Human rights act
- GMC requirements

Answer 119

- Statute (law)
- Consent by patient
- Public best interest

Answer 120

- Public Health Act 1984
- Road Traffic Act 1988
- Prevention of Terrorism Act 1989

Answer 121

Coordinated efforts to prevent harm to patients cause by the process of health care itself

Answer 122

Unintended event resulting from clinical care and causing patient harm

Answer 123

A situation in which events or omissions arising during clinical care fail to develop further

Answer 124

Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur

Answer 125

- Individual error - errors of individuals, blames individual for forgetfulness, inattention or moral weakness
- System error - conditions under which an individual works, tries to build defences to eliminate errors or mitigate their effect

Answer 126

- Unsafe acts committed by people in direct contact with the patient
- Usually short lived, often unpredictable

Answer 127

- Develop over time until they combine with other factors or active failures to casein adverse event
- Long lived and often can be identified and removed before they cause an adverse event

Answer 128

- Knowledge based - such as forming wrong intentions or plans as a result of inadequate knowledge/experience
- Rule based - encounter relatively familiar problems but apply wrong rule, either misapplication of a good rule or application of a bad rule
- Skills based - attention slips and memory lapses, involve the unintended deviation of actions from what may have been a good plan; people are prone to these types of errors, mainly due to interruption or distraction

Answer 129

- Deliberate deviation from some regulated code of practice or procedure
- They occur because people intentionally break the rules

Answer 130

- Routine - regularly performed shortcuts due to system, process or task being poorly designed or actions; may become tacitly accepted practice over time
- Reasoned - occasional reasoned deviation from a protocol or procedure which we believe we have good reason for making (e.g. time constraints), may be in patient's best interests
- Reckless - deliberate deviations from a protocol/code of conduct and include acts where opportunity for harm is foreseeable and ignored, although harm may never be intended
- Malicious - deliberate deviations from a protocol/code of conduct, where the intention is to cause harm

Answer 131

- National Patient Safety Agency (NPSA) 2001 - coordination of reporting and learning from mistakes that affect patient safety
- National Reporting and Learning System (NRLS) 2004 - national system for anonymous reporting go patient safety incidents, including near misses; all trusts now have local system for reporting, linked to the national system; also has an E-form for reporting incidents anonymously directly to the NPSA
- Medicines and Healthcare Products Regulatory Agency (MHRA) - ensures medicines, healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness and that they are used safely; monitoring of medicines and acting on safety concerns; responsible for adverse incident reporting system for medical devices

Answer 132

- Hospital mortality data
- Data on other measures of safety - reports of never events and serious incidents, NHS safety thermometer, patent safety dashboards
- Monitoring and inspections by regulators - care quality commission (CQC), NHS Improvement

Answer 133

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

Answer 134

- Report it - incident reporting systems
- Assess its seriousness
- Analyse why it occurred - root cause analysis
- Be open and honest with the affected patient and apologise - duty of candour
- Learn from the event and put in place action to reduce risk of repeat

Answer 135

- Accidental injury
- Asthma
- Respiratory illness
- Infective process
- Rashes
- Appendicitis

Answer 136

- Higher suicide rates
- Violence related incidents
- Road traffic accidents
- Behavioural differences between males and females - more likely to take part in 'risky' behaviour

Answer 137

Traffic accidents (>50%)

Answer 138

- Poor nutrition
- Overcrowding
- Lack of clean water
- Harsh realities that may make putting your health at risk the only way to survive or keep your family safe

Answer 139

- Reducing a family's work productivity
- Leading family to sell assets to cover the costs of treatment

Answer 140

- Affects physical, mental and social development
- Repeated absence at school
- Affect on parents and siblings
- Financial effect (family and community)
- Can be lifelong

Answer 141

Antenatal screening tests identify major abnormalities
- Alpha fetoprotein - raised in neural tube defects and some GI abnormalities
- Downs test - alpha fetoprotein and HCG
- Ultrasound - growth check, cardiac abnormalities, diaphragmatic hernia

Answer 142

- Blood spot test - PKU, cystic fibrosis, sickle cell disease, congenital hypothyroidism
- Physical examination

Answer 143

- Antenatal screening (12th week of pregnancy)
- Neonatal examination
- New baby review (14 days)
- 6-8 week check
- 1 year check
- 2-2.5 year check

Answer 144

- Take history
- Assess psychological and social situation
- Examination of mother - abdomen, vaginal exam (sometimes), BMI
- Examination of baby - weight, head circumference, appearance and movement, hips, heart, spine, eyes
- Health promotion - immunisations, breast-feeding, reducing risk of SIDS, car safety
- Assessment of parenting and emotional attachment

Answer 145

- Look for cyanosis, ventricular heave, respiratory distress, tachypnea
- Feel apex beat
- Listen or murmurs

Answer 146

Ball and socket joint of hip doesn't form properly - too shallow so femoral head is loose and can dislocate

Answer 147

- Barlows test - flex and adduct hip then push hip posteriorly, positive test causes femoral head to slip out of the acetabulum
- Ortolanis test - gently abduct hip, puts dislocated hip back in place

Answer 148

- Respiratory rate - 30-60 breaths per minute
- Heart rate - 100-160 beats per minute
- Temperature - 37 degrees celsius

Answer 149

- 8 weeks - 6-in-1 vaccine (1st dose), rotavirus vaccine (1st dose), MenB vaccine (1st dose)
- 12 weeks - 6-in-1 vaccine (2nd dose), pneumococcal (PCV) vaccine, rotavirus vaccine (2nd dose)
- 16 weeks - 6-in-1 vaccine (3rd dose), MenB vaccine (2nd dose)
- 1 year - Hip/MenC vaccine (1st dose), MMR (1st dose), PCV vaccine (2nd dose), MenB (3rd dose)

Answer 150

- Postnatal period
- Period of about 6-8 weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition

Answer 151

- Monitor progress of pregnancy to optimise maternal and foetal health
- Develop a partnership between the other and health professionals
- Exchange information that promotes choice - about lifestyle, location of birth, etc.
- Recognise deviations from the norm and refer appropriately
- Increase understanding of public health issues
- Provide opportunities to prepare for birth and parenthood

Answer 152

- MBRRACE-UK (mothers and babies - reducing risk through audits and confidential enquiries across the UK)
- NICE antenatal care guideline (2008, modified 2014)
- Evidence based practice
- Local policy/guidelines for practice
- Midwifery 2020
- National maternity review 'Better births'

Answer 153

- Personalised care
- Continuity of care
- Safer care
- Better postnatal and perinatal mental health care
- Multi-professional working
- Working across boundaries
- A fairer payment system

Answer 154

- Physical examination - weight, BP, urinalysis
- Blood tests - FBC, antibodies, ABO and Rh, HIV
- Psychosocial and emotional support - general wellbeing, work, financial, anxiety

Answer 155

- Chronic or acute disease - may be complicated with pregnancy
- Proteinuria - could indicate renal pathology
- Significant increase BP readings - pre-eclampsia, may lead to eclampsia (fits and convulsions)
- Significant oedema - hypertensive disorder?
- Uterus large or small for gestational age - lots of conditions affect these
- Malpresentation - cephalic or breach
- Infection - increases risk of miscarriage/stillbirth
- Social or psychological factors - mental health problems can lead to antenatal depression/postnatal depression

Answer 156

- Spontaneous miscarriage - loss of pregnancy before 24 completed weeks of pregnancy
- Ectopic pregnancy - fertilised ovum implants outside uterus (embryo grows in Fallopian tube or even abdomen)
- Termination of pregnancy
- Stillbirth - born after 24 weeks and does not show any sign of life

Answer 157

- Mother and Babies Reducing Risk through Audits and Confidential Enquiries across the UK
- Looked at standards of care and mortality and morbidity rates
- 2/3 of mothers died from medical and mental health problems, 1.3 from direct causes
- 3/4 of women who died had known mental health problems before they died

Answer 158

- Infection
- Haemorrhage
- Thrombosis
- Hypertensive disorders (eclampsia)

Answer 159

- Perineal care - infection, inadequate repair, wound breakdown/non-healing
- Urinary retention
- Dyspareunia - difficult or painful sex
- Headache
- Fatigue
- Backache
- Constipation
- Haemorrhoids
- Breast and nipples - redness, painful, cracked, mastitis

Answer 160

- 50-80% 'The blues' - very weepy over small things, time-limited, recovers very quickly, if it continues then begins o worry about postnatal depression
- 10-15% Postnatal depression - tiredness, worthlessness, low mood
- 0.2% Puerperal psychosis - severe episodes of mental illness that begins suddenly, mania, depression, confusion, hallucinations, delusions

Answer 161

Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital

Answer 162

- General anaesthesia, danger of Mendelsohns' syndrome (aspiration pneumonia), paralytic ileus
- Surgical techniques, quite radical abdominal surgery, risk to other internal organs from surgical trauma
- Childbearing risks for further births

Answer 163

- Birth seen as a dangerous journey, only normal in retrospect, therefore assume the worst
- Low threshold for intervention (to fix defective bodies)

Answer 164

Birth is seen as a normal physiological process which women are uniquely designed to achieve

Answer 165

- Unintended pregnancy - delay in seeking prenatal care and having a premature baby, higher levels of stress and depression
- Pregnancy may or may not fit with the mother's plans
- Social disapproval for pregnancy out of wedlock and teenagers

Answer 166

- Established normality in childbearing as the midwife's role - refer to doctors as soon as abnormality occurs
- This ensures equal access to midwives and doctors for childbearing women of all socioeconomic standing

Answer 167

- 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 of effective obstetric analgesia

Answer 168

- Medicalisation
- Depersonalisation of birth
- Lack of privacy
- Inflexibility of labour and birth practices
- Limitation of resources

Answer 169

- You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients
- identifying signs of abuse or neglect early and taking action quickly are important in protecting children and young people
- Know what to do if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect
- Act on any concerns about a child or young person who may be at risk of, or suffering, abuse or neglect

Answer 170

- Baby - audible and visible swallowing, sustained rhythmic suck, relaxed arms and head, moist mouth, regular soaked nappies
- Mother - breast softening, no compression of nipples at end of feed, relaxed

Answer 171

- Nipple pain
- Engorgement
- Mastitis
- Inverted nipple
- Ankyloglossia (tongue ties)
- Sleepy baby

Answer 172

The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Answer 173

Quality management produces improved quality, reduced costs, increased productivity and an increased market share

Answer 174

- Medicine has a weak evidence base
- Large variations in clinical practice - doctors do give different treatments to patients with similar needs and personal characteristics
- Failure to measure success outcomes in healthcare

Answer 175

- Hospital episode statistics (HES) - details referring GP, procedures given, duration of stay and discharge/death, lack of basic national data in primary care
- Patient reported outcome measurements (PROMs) - before procedure and after procedure quality of life measurement slowly developing
- Reference cost data - cost data are poor

Answer 176

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

Answer 177

- Care Quality Commission (CQC) - regulates 'quality' and financial performance of all health and social care providers, public and private, provides regulatory framework, license all providers of health and social care
- NHS Improvement (formerly 'Monitor') - ensures financial obligations are met in terms of balancing income and expenditure
- National Institute for Health and Clinical Excellence (NICE) - set standards for treatment

Answer 178

- Royal colleges
- GMC
- Professional audit

Answer 179

- 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

Answer 180

A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish

Answer 181

- Physical neglect
- Educational neglect
- Emotional neglect
- Medical neglect

Answer 182

- Malnutrition, begging, stealing or hoarding food
- Poor hygiene, matted hair, dirty skin, body odour
- Unattended physical or medical problems
- Frequent lateness or absence from school
- Inappropriate clothing, especially inadequate clothing in winter
- Frequent illness, infections or sores
- Being left unsupervised for long periods

Answer 183

- Physical abuse - deliberate aggressive actions on the child that inflict pain
- Neglect - failing to provide a child's needs
- Psychological abuse - behaviours towards children that cause mental anguish or deficits
- Sexual abuse - when someone touches a child in a sexual way or commits a sexual act with him or her

Answer 184

- Parents - procreative autonomy, parents wishes regarding reproductive choice should be respected, state interference should be minimal
- Future or existing child - parents wishes should not be respected if not in interests of the future or existing child
- Their parties, including the state - use of resources, health care providers objections of cosncience

Answer 185

'A woman shall not be provided with fertility treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father)'

Answer 186

- Fertile couples don't have to meet this criterion
- Predicting the welfare of future children is very difficult
- Research suggests not the case that a father is always required for a child to flourish

Answer 187

Continues to talk about a duty to take account the welfare of the child in providing fertility treatment (hence, welfare criterion remains) but replaces reference to 'the need for a father' with 'the need for supportive parents', thus valuing role of all parents

Answer 188

- Abortion ends the life of a foetus.
- Human foetus has the moral status of a person
- It's wrong to end the life of a person or something with moral status
- Therefore, abortion/termination of pregnancy is morally wrong

Answer 189

- To have control over one's reproductive capabilities
- The freedom to choose whether or not to have children

Answer 190

A person shall not be guilty of an offence under the law relating to abortion when pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- Pregnancy has not exceeded 24 weeks
- Termination is necessary to prevent injury to physical or mental health
- Continuing pregnancy would involve risk to the life of the pregnant woman
- Risk that if the child was born it would suffer from physical or mental abnormalities

Answer 191

- Procreative autonomy
- Helps get around fertility problems
- More successful than other forms of assisted reproductive technology
- Can help single women and same-sex couples have a child

Answer 192

- Involves destruction of embryos
- Higher risk of multiple pregnancy with associated risks of mortality and morbidity
- Is 'unnatural'
- Encourages the mentality which views people as things which can be bought or sold as wanted
- IVF babies are more at risk of birth defects than naturally conceived babies
- Psychological and physical health risk on parents
- ART can be expensive

Answer 193

- Genetic profiling of embryos prior to implantation 9as a form of embryo profiling), and sometimes even oocytes prior to fertilisation
- Can be sued for avoiding genetic diseases
- Issues - sex selection, saviour siblings - 'Designer babies'

Answer 194

- Objections should always be respected - the autonomy of the medical provider is paramount, no-one should be made to do something that goes against their strongly held personal beliefs
- Objections should never be respected - women's interests should always take priority, sometimes argued that if doctors don't like this then shouldn't have chosen medicine as a profession
- Objects can sometimes be respected (the GMC's position) - it might be possible for women's interests to be met while at the same time not requiring doctors to do something that would cause them a great deal of distress, e.g. perhaps can refer patients to abortion services or provide patients with information

Answer 195

The Family Law Reform Act of 1969

Answer 196

Child (under 16) can consent to medical treatment if deemed competent by medical professional, without need for parental permission or knowledge

Answer 197

Doctor can give contraceptive advice and treatment to a person under 16 if they are mature and intelligent, likely to continue to have sex, and if the treatment is in their best interests

Answer 198

- Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
- Explain what the examination will involve
- Get consent and record that the patient has given it
- Offer a chaperone
- Give the patient privacy to undress

Answer 199

- Screening/identification of actual and/or 'at risk' patients
- Pregnancy and postnatal period are 'window of opportunity; to make lifestyle changes - smoking cessation, diet, exercise
- Sign-posting, liaison and referral - mental health services, MDT working
- Health promotion - women and family
- Source of information - bonding, breastfeeding
- Reassurance and support
- Safeguarding - vulnerable adult or child

Answer 200

- A documented, individualised postnatal care plan for every woman
- Communication, particularly about transfer of care
- Information giving - empower women to take care of their own health and their baby's health
- Assess the health and wellbeing of the woman and her baby
- Alert women to signs and symptoms of potentially life-threatening conditions
- Encourages breastfeeding - large proportion of postnatal care
- Assess emotional wellbeing
- Parents should be given information regarding assessing baby's general condition, identifying common health problems and how to contact a healthcare professional or emergency services if needed

Answer 201

- Midwives
- GPs
- Obstetrics
- Support workers
- Health visitors
- Maternity care assistants
- Public health practicitioners

Answer 202

Postnatal care should be a continuation of the care the woman received during her pregnancy, labour and birth, and involve planning and regularly reviewing the content and timing of care, for individual women and their babies

Answer 203

- Separate documentation
- Poor working relationship
- Lack of awareness and appreciation of the roles and responsibilities of others
- Limited time and resources
- Overlapping of roles and duplication of services
- Poor communication
- Lack of information sharing
- Lack of collaboration
- Lack of trust and confidence in the abilities of other agencies
- Increased workload
- Lack of appropriately trained staff

Answer 204

- Personal experience is biased in various ways
- Research reports findings for more patients than we can hope to see in personal experience
- Research involves the application of scientific method - testing of hypotheses, systematic data collection, analysis-designed to minimise bias
- Recommendations have been assessed for their clinical and cost effectiveness for the NHS

Answer 205

1. Identify a clinical problem
2. Basic research - laboratory based
3. Applied (clinical) research
4. Clinical care

Answer 206

Gap between scientific understanding and patient care

Answer 207

- Characteristics of the recommendations - easy to follow, compatible with existing norms, need for new skills, complexity of recommendations
- Characteristics of the adopters - knowledge, attitudes, skills and abilities
- Characteristics of the organisation - limitations and constraints, organisational culture
- Characteristics of the environment - social influence

Answer 208

Facilitate the uptake and continuing use of evidence-based policy and practice, focusing on recurrent problems within system of care to improve:
- Performance
- Professional development
- Service-user outcomes

Answer 209

- Engage participants across organisational levels
- Foster environment where improvement and innovation are viewed as normal
- Empowering staff to strive for change
- Provide knowledge and methods to implement change
- Remove barriers to change

Answer 210

- Revision of professional roles
- Introduction of MDTs
- Change in skill mix, or in the setting of service
- Facilitate audit and benchmarking cycles to identify variations in practice and outcomes that may be targets for QI efforts
- Network recognition for high quality practice
- Promote inter-institutional communication and collaboration (and inter-institutional competition)

Answer 211

- Passive dissemination of information, such as distribution of educational materials or didactic lectures, is generally ineffective in driving change
- Multifaceted intervention that act of different levels of barriers to change are more likely to achieve improvements in policy and practice
- Key - tailors to the key barriers, no just 'the usual approach'

Answer 212

- Annual reward and incentive programme detailing GP practice achievement results
- Enables commissioners to reward excellence across key domains
- Aims to improve standards of care by assessing and benchmarking the quality of care patients receive - compares delivery and quality of care against previous years

Answer 213

- Improvements associated with financial incentives seem to be achieved at the expense of small detrimental effects on aspects of care that were not incentivised
- Following the removal of incentives, level of performance across a range of clinical activities generally remain stable

Answer 214

- Friends and family test - incentivise high performing providers
- Improvement against the NHS safety thermometer, particularly pressure ulcers
- Improving dementia and delirium care
- Improving diagnosis in mental health

Answer 215

- 35% of 65-79 year olds
- 45% of 80-89 year olds
- 55% of 90+ year olds

Answer 216

- Osteoporotic fractures
- Head injuries
- Contusions, lacerations
- Psychological problem - fear of falling, social isolation, depression
- Increase in dependence and disability
- Impact on carers - time and anxiety
- Institutionalism

Answer 217

- Muscle weakness
- History of falls
- Gait deficit
- Balance deficit
- Visual deficit
- Arthritis
- Impaired activities of daily living (AoL)
- Cognitive impairment
- Age (>80 years)
- Medical conditions - PD, stroke, hypotension, depression, epilepsy, dementia, arthritis, peripheral neuropathy, dizziness and vertigo

Answer 218

- Increase activity - diversity of physical activity
- Weekly walk for exercise
- Strong family networks
- Multifactorial falls risk assessment
- Multifactorial intervention
- Education and information

Answer 219

- Brisk walking
- Residential care setting - causes an increase
- High intensity strength training - increases injury and strain
- Educational and behavioural preventions alone - need further methods

Answer 220

- Quality adjusted life year
- 1 QALY = 1 year in perfect health
- e.g. if an illness reduces quality of life by 20% (0.2) and this affects 10 people then 2 QALY are lost

Answer 221

£1.3 billion

Answer 222

- £12,000 per patient
- Around £720 million per year

Answer 223

Fracture of the neck of femur

Answer 224

- Extracapsular - the bone outside the joint capsule breaks; fixed with sliding hip screw, intramedullary nail
- Intracapsular - the bone within the joint capsule breaks; fixed by internal fixation (screws, nails, plates and rods)

Answer 225

- Death of bone tissue due to lack of blood supply
- Can lead to tiny breaks in the bone and the bone's eventual collapse

Answer 226

Osteoporosis

Answer 227

- Low bone mineral density (BMD) is associated with increased fracture risk
- Age - every 5 year increase doubles the risk
- Female gender
- Low body weight (correlates with bone density)
- Family history of hip fracture
- Prior history of hip fracture
- Smoking
- Ethnicity - people of Afro-caribbean descent have very low fracture risk
- Corticosteroid use
- Medications e.g. psychotropic drugs

Answer 228

- Fall prevention
- Bone protection - medication (bisphosphonates, calcium & vitamin D), hip protection

Answer 229

Avoidance of disease before any signs or symptoms develop

Answer 230

Avoidance of progression or later problems, signs or symptoms present

Answer 231

- Primary - no history of stroke or TIA
- Secondary - after either of these have occurred

Answer 232

- The majority of people who suffer a stroke are not at high risk of stroke (e.g. 75% have 'normal' blood pressure)
- But if the whole population changes their health behaviour via public health mechanisms, this would lead to a much greater effect

Answer 233

- Large potential benefit to community
- Low potential benefit to individual
- May be low perceived benefit to individual

Answer 234

- Larger potential benefit to individual
- Smaller effect in population rate of stroke
- Many of the conditions you treat are asymptomatic
- Many of the treatments have side effects

Answer 235

- people who have already had one - secondary prevention reduces risk in these people
- 1/5 people with stroke have another after 3 months

Answer 236

- Ischaemic - clopidogrel, statins, anti-hypertensives, anticoagulant if AF
- Haemorrhagic - anti-hypertensives

Answer 237

- Men are at a 25% higher risk of having stroke and at a younger age compared to women
- However, as women tend to live longer there are more total incidences of stroke in women

Answer 238

- Age
- Gender
- Race - South Asian descent with western lifestyle
- Family history - rare congenital (in young people - CADASIL)

Answer 239

- High blood pressure - biggest risk factor
- Diabetes
- Atrial fibrillation
- Smoking
- Hyperlipidaemia
- Obesity

Answer 240

Reducing blood pressure after stroke reduces risk of stroke recurrence

Answer 241

- Misinformed
- Not caring
- Side effects of tablets
- Forgetfulness
- Depression
- Cognitive impairment

Answer 242

- Distortion of the relationship between an exposure and outcome due to shared relationship with something else
- Confounders can either increase associated associated between exposure and outcome, or decrease association between exposure and outcome

Answer 243

- Restriction - limit the participants of your study who have possible confounders; means that you have less data and difficult with multiple confounders
- Matching - you create a comparison group that is matched on the possible confounder, make case and control group as similar as possible on the confounder and then ask about exposure status; use for strong confounders like age and sex
- Stratification - analyse exposure-outcome association in different subgroups of the confounder, recombine data and use a weighted average of the strata; limitations - to take into account all confounders would require lots of strata and you may run out of data to fill all possible options n your strata
- Multiple variable regression - you can adjust for the effects of multiple confounders, try and produce a linear model between the outcome and the different exposures; allows for adjustment of estimates for confounding

Answer 244

Way to limit confounding, often used to control for differences in age groups when comparing rates of disease in two populations with different age structures

Answer 245

Ratio between the observed number of deaths in a study population to the number of expected deaths

SMR = observed number of deaths / expected number of deaths

Answer 246

Required we know the age-specific rates of mortality in all populations under study

Answer 247

Only requires that we know the total number of deaths and the age structure of the study population

Answer 248

- There is a limitless demand for health, people can always 'be more healthy' which created high demand
- limited resources - supply of money, staff, etc. is finite

Answer 249

- The patient's condition may deteriorate while waiting and in some cases the effectiveness of the proposed treatment may be reduced
- Experience of waiting can be extremely difficult distressing in itself
- Patient's family life may be adversely affected by waiting
- Patient's employment circumstances may be adversely affected by waiting
- Excessive waiting times may be symptoms of inefficiencies in the healthcare system and should be addressed as part of good management

Answer 250

- Average waiting times (mean or median)
- Proportion who waited longer than 'x number of days'
- Average wait of people currently on the list

Answer 251

- The backlog - implies a need for occasional emergency injection of funds
- Demand management - waiting acts as a 'price' to deter frivolous use
- Allows NHS resources to be fully employed - don't want lots of spare capacity as this is a waste
- Waiting lists are caused by underfunding and inefficiency

Answer 252

- Manage demand - ensuring each referral represents the most appropriate decision for the care of the individual patient
- Manage the queue - ensuring waiting lists are well managed and patients are called for treatment in appropriate order
- Manage capacity - providing efficient and effective services that meet the level of demand from appropriate referrals
- Provide leadership - ensuring that all parts of the local NHS work together to achieve waiting time improvements in the best interests of patients

Answer 253

- Performance management of Trusts and PCTs based on achievement of target waiting times
- Hospitals receive an overall performance score and managers could lose their jobs if targets missed

Answer 254

- No inpatients waiting longer than 3 months
- Outpatients reduced, significant increased expenditure alongside this, however funding has now remained constant meaning NHS is struggling despite increased demand

Answer 255

- Sacrifice of professional autonomy - managers pressuring doctors, may be forced to treat les urgent due to waiting times
- unmeasured performance sufferers - things that don't have a target may suffer
- Adverse behavioural responses - e.g. emergency patients waiting in ambulances not emergency rooms, not classed as being in A&E until they are through the doors so essentially cheating
- Data manipulation and fraud

Answer 256

- Clinical urgency
- Clinical severity
- Potential health gain
- Productivity and economic loss
- Equity waiting e.g. poverty
- Length of time waiting

Answer 257

- Social impact - difficult to have conversations, isolation, intimacy issues, problems at work
- Psychological impact - anger, low confidence, frustration, depression, embarrassment
- Practical issues - doorbells, phones, theatre and cinema, TV, alarms

Answer 258

- Aphasia (and sometimes dysphasia) - difficulty in the generation of speech and sometimes also in its comprehension
- Dysarthria - difficult or unclear articulation of speech that is otherwise linguistically normal (due to weakness of muscles used to speak)
- Dyspraxia - affects movement and coordination, cannot move muscles int he correct order and sequence to make the sounds needed for clear speech

Answer 259

- Not being able to express yourself clearly can be very isolating
- Depression
- Frustrating
- May not be able to participate in activities they used to enjoy
- Tiring - communicating may require a lot of effort

Answer 260

- Determination of fitness to drive and other similarly dangerous activities
- Determination of intent for alleged criminal actions

Answer 261

- Group 1 which applies to cars, motorbikes, and most other small vehicles - need to be seizure free for 12 months
- Group 2 which applies to bigger vehicles such as lorries, heavy goods vehicles and other specialised types of vehicle - unlikely to qualify for group 2 licence, need to be seizure free for 10 years and have not taken epilepsy medicines for 10 years

NEW RULES relating to whether people can drive if:
- They have only had seizures while they sleep
- They have only had seizures that do not affect their consciousness
- Their doctor changed their dosage or medication, but they have now gone back to the original dosage or medication

Answer 262

- Complementary - non-mainstream practice is used together with conventional medicine
- Alternative - non-mainstream practice is used instead of conventional medicine

Answer 263

- Acupuncture - fine needles are inserted at certain sites in the body for therapeutic or preventative purposes
- Chiropractic - spinal manipulation aims to treat 'vertebral subluxations' which are claimed to put pressure on nerves
- Herbal medicine - medicines with active ingredients made from plant parts
- Homeopathy - based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself
- Osteopathy - moving, stretching and massaging a person's muscles and joints

Answer 264

- Self-healing is triggered
- Longer-term effects may be due to physiological (re-)learning and behavioural/lifestyle changes integral to treatments
- Each therapy has its own mechanism(s) - mostly poorly understood

Answer 265

- Regulatory issues
- Financial concerns in NHS
- Tribalism - different medical specialties 'hold on' to their patch
- Inertia - resistance to change
- Mixed evidence of effectiveness - not all are properly evidence-based

Answer 266

- Patient choice
- Preventative healthcare agenda
- Commissioning changes
- Personal budgets
- Growing evidence base

Answer 267

Osteopathy

Answer 268

- Back pain
- Repetitive strain injury
- Changes to posture in pregnancy
- Postural problems caused by driving or work strain
- The pain of arthritis and sports injuries

Answer 269

- Back, neck and shoulder problems
- Joint, posture and muscle problems
- Leg pain and sciatica
- Sports injuries

Answer 270

- MSK patients
- Fertility/pregnancy - has become much more popular
- Neurological pain
- Depression
- Eczema
- Chronic pain
- Irritable bowel

Answer 271

Effectiveness gap - a clinical area where available treatments are not fully effective or satisfactory for various reasons including lack of efficacy, adverse effects and acceptability to patients

Answer 272

- Acupuncture correlated with physiological parameters i.e. with decreases in brain flow
- Acupuncture can be seen as having an overall effect vs usual care
- More effective than no treatment or sham treatment for lower back pain (indicate it is more than a placebo) but there are no differences in effectiveness compared with other conventional therapies
- Acupuncture, osteopath, chiropractic shown to be effective when compared to usual care
- As is the case with biomedicine, more and better research is needed

Answer 273

- Is the effect too small and not clinically relevant?
- NSAIDs are commonly given for chronic back pain - NSAID vs placebo and acupuncture vs placebo have similar effect for pain reduction

Answer 274

- Lower back pain - consider manual therapy, do not offer acupuncture
- Osteoarthritis - manipulation and stretching should be considered as an adjunct to core treatments, do not offer acupuncture
- Headache/migraine - consider a course of up to 10 sessions of acupuncture over 5-8 weeks

Answer 275

- Lack of insight - person suffers from some disability but seem unaware of the existence of their disability
- Cognitive impairment - e.g. dementia
- Presence of psychosis
- Severe depressive symptoms
- Learning disability

Answer 276

- Patients generally happier if they can make decisions
- Enables patients to have self-determination, autonomy
- Likely to facilitate other positive goods - good doctor-patient relationship
- A professional requirement (GMC)
- A legal requirement - Mental capacity act (2005)

Answer 277

- Using a different form of communication
- Providing information in a more accessible form
- Treating a medical condition affecting the person's capacity
- Having a structured programme to improve a person's capacity

Answer 278

Mental capacity act (2005)

Answer 279

A person lacks capacity if they are unable to:
- Understand information that may be relevant to the decision, including the consequence
- Retain information, even for a short time
- Use or weigh information to make decisions
- Communicate decision

Answer 280

- Presumption of capacity - a person must be assumed to have capacity until proven otherwise; assumption can be over-ridden if shown to lack capacity for that decision at that time
- Right to be supported to make their own decisions - use different forms of communication, provide information in different formats, treat a condition that is impacting capacity thus restoring capacity
- Right to make eccentric or unwise decisions - a person is not to be treated as unable to make a decision merely because it is an unwise one
- Best interests - a decision made under the MCA for someone lacking capacity must be done in their best interests
- Least restrictive intervention - before the decision is made you should explore other less restrictive options

Answer 281

Approximately 850,000 people

Answer 282

- Patient noticing changes - forgetfulness, difficulty with names and finding the right word, embarrassment in social situations
- Family or friends noticing changes - repetitive, forgets social arrangements, skills deteriorating, withdrawing
- Delirium - acute confusion with fluctuating level of consciousness, agitation, hallucinations, etc.
- Social crisis - e.g. death of a spouse reveals cognitive dysfunction and impairment

Answer 283

- Denial (with or without insight) - patient attributes all problems to old age, often accompanied by anger at the suggestion that there is anything wrong
- Grief reaction - similar reaction to receiving diagnosis of any serious illness
- Acceptance/positive coping strategies - need to reconsider the future

Answer 284

- Insight and stage of illness - ability to remember and process information
- Type fo dementia
- Previous personality, relationship, and support

Answer 285

- Confirmation of something they have long suspected
- Fear
- Anger
- Grief

Answer 286

- understanding of illness
- Patient's reaction
- Nature of the relationship with the patient and what else is happening

Answer 287

- Know what it is that you are dealing with
- Access to treatments
- Access to support services
- Information/education
- Planning for the future - financial affairs, etc.
- Assess and manage risks - e.g. driving, etc.

Answer 288

- Patient - loss of self-esteem, may find communication difficult, loss of independence and autonomy, change in social roles and relationships, impact on ADLs
- Partner - relationship becomes skewed, practical, emotional, financial, strained relationship with family/friends
- Child - role reversal, competing demands, conflict between family members, effect on young children, previous relationship
- Carers - stress, physical care, poor sleep, constant vigilance, loss of support, unable to take time off sick

Answer 289

2/3 = £17.4 billion

Answer 290

- More vulnerable
- May struggle to discuss their feelings and experiences or remember what happened to them
- Can be hard to detect abuse

Answer 291

- Advanced statement of wishes - wishes and preferences about treatment/care they would like (NOT legally binding hence can use best interests judgement)
- Advanced decisions/directives - a decision to refuse treatment (LEGALLY BINDING so should always be followed)

Answer 292

- Extends patient autonomy to apply in situations where they don't have capacity as defined under the MCA 2005
- A valid AD that refuses treatment should always be followed
- ADs allow patients refuse treatment but not to demand treatments

Answer 293

- Patient is 18+ - note MCA is for 16+ but only 18+ can refuse treatment
- Patient lacks capacity at the time of treatment but had capacity at time of making AD
- Properly informed patient and statement is clear and applicable to current situations
- ADs can be used to refuse life-saving treatments but cannot be used to refuse basic care e.g. food/water

Answer 294

Advanced directive for bipolar disorder

Answer 295

- Respect patient autonomy
- Encourages forward planning
- Patient will be less anxious about unwanted treatment
- May lower healthcare costs as people opt out for less aggressive treatments

Answer 296

- Difficulty to verify if the patient's opinion has changed since making AD
- Difficult to ascertain whether the current current circumstances are what the patient foresaw when making AD
- Possibility of coercion on behalf of the patient
- Possible wrong diagnosis
- Can patients imagine future situations sufficiently and vividly enough to make their current decisions adequately informed?

Answer 297

- Nazi medical experiments (Nuremberg trials)
- Willowbrook study - injected vulnerable children with Hep B to develop vaccine
- Tuskegee syphilis study - African-American men given syphilis but not given antibiotics, researchers wanted to see disease progression
- Alder Hey - retaining children organs without consent
- Wakefield - MMR scandal (autism claim)

Answer 298

The Nuremberg code resulted from the Nuremberg trials. It was an early code for research ethics principles, including:
- Need for voluntary consent
- Avoid all unnecessary physical and mental suffering and injury
- Conducted only by scientifically qualified persons

Answer 299

Includes requirement that any human research is subject to independent ethical review and oversight by properly convened committee

Answer 300

- Usefulness - valid, good method, hasn't been done before, strong justification
- Necessity - does it need to be done this way?
- Risks - risks should be as low as possible, sometimes balance minimal risk with benefits
- Consent - valid (competent, voluntary, informed), deception is sometimes needed e.g. psychological studies
- Confidentiality - respect patients information
- Fairness - who benefits? will it favour particular population group?
- Approval - from research ethics committee

Answer 301

Voluntary, informed, patient is competent

Answer 302

- Not putting pressure on patients or volunteers
- Not offering inappropriate (financial) inducements
- Not threatening/imposing sanctions if they don't take part

Answer 303

- Information sheets
- Presentation of information - no jargon, easy to understand
- Summary of key points
- Opportunity to ask questions
- Time to decide - at least 24 hours

Answer 304

- Confidentiality is the state of keeping or being kept secret or private
- It is important for patient trust and for ensuring valid results
- All patient information is confidential

Answer 305

- Limit access to identifiable information
- Securely store data documents
- Assign security codes to computerised records
- Properly dispose, destroy or delete study data/documents
- Encrypt identifiable data

Answer 306

Body responsible for ensuring that medical experimentation and human research are carried out in an ethical manner in accordance with national and international law

Answer 307

- To protect participants
- Make sure no harm to researchers
- Researcher will not be covered is a claim regarding the research is made against them
- Many publications will not accept research that was not ethically approved
- Funders will not provide financial support without ethical approval

Answer 308

- Research involves humans
- Research involves confidential information
- Research involves biological material (embryos, stem cells, etc.)

Answer 309

- NHS research ethics committees
- Higher education institution (HEI) research ethics committees
- Gene therapy advisory committee
- Social care research ethics committee
- Ministry of defence research ethics committee

Answer 310

- Consent for storage and use of tissue for 'scheduled purposes' is required for tissues from living or deceased persons
- These purposes include research in connection with disorders, or the functioning of the human body
- However, consent is not required to use tissue obtained from living patients if the tissue is anonymous to the researcher and the project has research ethics approval

Answer 311

- 29% men
- 28% women

Answer 312

- Risk factors improved - fewer smokers, cholesterol better controlled, HTN controlled
- Treatments - medical interventions improved for various cardiac conditions

Answer 313

Lower social class at higher risk - health behaviours

Answer 314

- Elevated blood cholesterol
- High LDL, low HDL
- High BP
- Diabetes
- Smoking
- Obesity
- Excessive alcohol
- Inactivity
- Excessive stress

Answer 315

The probability of an event in a given time period

Answer 316

Risk ratio = risk for exposed / risk for non-exposed

Answer 317

Risk difference = Risk for exposed - Risk for non-exposed

Answer 318

A ratio of the odds of an event in an exposed group to the odds of the same event in a group that is not exposed

Answer 319

OR = ad/bc

a = disease with exposure (case)
b = no disease with exposure (control)
c = disease with no exposure (case)
d = no disease with no exposure (control)

Answer 320

The risk of disease will increase as the exposure prevalence or relative risk increases

Answer 321

Lung cancer

Answer 322

- Smoking
- Radon
- Asbestos
- Environmental tobacco exposure
- Genetics
- Other lung diseases
- Prior radiation in chest area

Answer 323

- Small cell (13%)
- Non-small cell (87%) - adenocarcinoma (>40%), squamous cell carcinoma (20%), large cell carcinoma (2%)
- Mesothelioma

Answer 324

1/4 of the world population = approx. 2 billion people

Answer 325

1.5 million people (in 2020 according to WHO)

Answer 326

- Urban homelessness
- IV drug use
- Growing neglect of TB control programmes
- AIDS epidemic

Answer 327

Spring/summer

Answer 328

- Put more people on ART
- New vaccine
- Improved drugs
- Diagnose better

Answer 329

A preventative measure that brings large benefits to the community offers little to each participating individual

Answer 330

- Appropriate to individual
- Motivated subject
- Motivated clinician
- Cost-effective resource use
- benefit for risk is high

Answer 331

- Screening is difficult
- palliative and temporary
- Limited potential as not many people
- Labelling

Answer 332

Large potential as targeting many people

Answer 333

- Population paradox - small perceived individual benefit
- Poor motivation can cause compliance issues
- Benefit for risk is low

Answer 334

- Occupational asthma
- COPD
- Pneumoconiosis
- Toxic pneumonitis
- Hypersensitivity pneumonitis
- Benign pleural disease
- Infections including TB
- Malignancy of lung and pleura

Answer 335

- Better environmental control an health and safety - e.g. from mid 20th century with coal mining, etc.
- Depends on health of the population and local industry
- Diagnosis of occupational lung disease (e.g. occupational asthma) has improved
- Biological factors - predisposing/protective factors

Answer 336

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

Answer 337

- Bakers
- Welders
- Paint sprayers
- Laboratory workers

Answer 338

- Symptoms worse at work and better away from work e.g. weekends and holidays
- Peak flow falls at work and improves away from work

Answer 339

- Coal mining
- Agricultural jobs
- Contraction workers
- Dock workers
- Brick making

Answer 340

Occupational restrictive lung disease caused bye inhalation of dust (coal dust, silica, asbestos)

Answer 341

- After around 10 years of coal mining, small nodules are present
- Shouldn't cause major impairment in lung function
- Some coal workers have symptoms of chronic bronchitis (cough)

Answer 342

- Occurs in coal workers especially fi the coal they work with is heavily contaminated with silicates
- Very serious - scarred, fibrotic tissue distorts the remaining lung (gross obstruction and restriction)

Answer 343

- 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

Answer 344

- Deposition of iron in tissue
- Iron has no effect on lungs - no associated fibrosis or narrowed airways

Answer 345

- Acute inhalation of a substance that causes symptoms immediately
- Can be caused by chlorine, ammonia, organic chemicals, metallic compounds
- Form of acute respiratory distress syndrome

Answer 346

- Type 3 hypersensitivity reaction (immune complex deposition)
- It is an inflammation of the alveoli within the lung caused by hypersensitivity to inhaled organic dust

Answer 347

- Bird fancier's lung - due to feathers and bird droppings
- Farmer's lung - due to mouldy hay (moulds and bacteria)
- Metalworking fluids HP - due to mist from metalworking fluids (non-TB mycobacterium)

Answer 348

- A natural occurring silicate mineral
- Used a lot in the 1950s-60s as a building material - fire retardant and could be used as cement
- In the 1960s it was found to cause malignant mesothelioma (pleural tumour) - only a small amount of asbestos was found to cause this

Answer 349

- Serpentine - curly, white asbestos (relatively harmless), cleared with mucociliary escalator
- Amphiboles - short, sharp, blue/brown asbestos (have malignant potential)

Answer 350

- Cancer of the mesothelium almost inevitably caused by occupational exposure asbestos
- Latency period of around 40 years

Answer 351

Disability benefits centre of benefits agency (DSS)

Answer 352

Systematic and quantitative way of making healthcare decisions e.g. when presented with two options

Answer 353

- Decision process is logical and rational
- A rational decision maker will choose the option to maximise utility (the desirability or value attached to a decision outcome)

Answer 354

1. Structure the problem as a decision tree - identifying choice, information (what is and is not known) and preferences
2. Assess the probability (chance) of every choice branch
3. Assess (numerically) the utility of nervy outcome
4. Identify the option that maximises unexpected utility
5. (Possibly) Conduct a sensitive analysis to explore effect of varying judgements

Answer 355

- Squares - indicated decision, represents choice between actions
- Circles - indicated chance (probability), represents uncertainty, potential outcomes of each decision

Answer 356

Expected utility = utility value x probability

Answer 357

Sensitive analysis explores what would happen if the probabilities or utility values were slightly different to the ones you are using - calculate effect of uncertainty on decision

Answer 358

- Preference sensitive - the person might feel strongly about the side effects of the treatment
- Probability sensitive - sensitive to changes int he chance of different outcomes

Answer 359

- 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 then the generated numbers
- Can be used for individual decisions, population levels decisions and for cost-effectiveness analysis

Answer 360

- Probability estimates - required data sets to estimate probability may not exist; subjective probability estimates are subject to bias
- Utility measures - individual 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; the approach is reductionist

Answer 361

Functioning and disability are multi-dimensional concepts relating to:
- Body functions and structures - physiological functions and anatomical parts of the body, including cardiac and respiratory systems
- Activities
- Participation of people in life
- Environmental factors

Answer 362

- Active holistic care of patients with advanced progressive illness
- It aims to treat or manage pain and other physical symptoms and will also help with any psychological, social or spiritual needs

Answer 363

- Improves quality of life
- Provides relief from pain and other distressing symptoms
- Supports life and regards death as a normal process
- Doesn't quicken or postpone death
- Combines psychological and spiritual aspects of care
- Offers a support system to help people live as actively as possible until death
- Offers a support system to help the family cope during a person's illness and in bereavement
- Uses an MDT approach to address the needs of the person who is ill and their families

Answer 364

Core aspect of care for all patients and their families with advanced disease by all health professionals

Answer 365

Patients (and carers) with unresolved symptoms and complex psychosocial issues, with complex end-of-life and bereavement issues

Answer 366

- NHS - community/hospital clinic nurse specialist, some consultants, some inpatient units, macmillan
- Voluntary - hospice services, inpatient beds, independent charities (Marie Curie, Sue Ryder), macmillan

Answer 367

- Branch of palliative care - caring for people who are nearing the end of life
- 'End of life care pathway' - last 48 hours of life

Answer 368

- Inequality of service provision and standards
- Funding
- Training, recruitment and retention
- Maintaining a sense of humanity and compassion - due to increasing technologies and treatment options for management of disease

Answer 369

Recognises pain as being physical, psychological, social and spiritual

Answer 370

- District nurse - primary health care team, community based, generic palliative care skills, 'hands on' nursing skills
- Practice nurse - primary health care team, practice based, generic palliative care skills, 'hands on'
- Marie Curie nurse - community based, arranged by district nurse, specialist palliative care skills, 'hands on'
- Macmillan nurse - community or hospital based, specialist palliative care advice, support, resource

Answer 371

- Most people wish to die at home
- Few people wish to die in hospital
- Most people die in hospital
- Hard to plan because you don't know when it will happen

Answer 372

Do Not Attempt CPR - decision made and recorded in advance, applies to those present if a person subsequently suffers sudden cardiac arrest or dies

Answer 373

- Numbness
- Yearning/pining and anger
- Disorganisation and despair
- Reorganisation

Answer 374

- Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, numbness
- Somatic sensations - stomach, chest, throat, sensitivity to noise, depersonalisation, breathlessness, muscle weakness, lack of energy, dry mouth
- Concentration impairment, preoccupation with the deceased, hallucinations, disbelief
- Sleep and appetite disturbance, absent-mindedness, social withdrawal, dreams of deceased, avoidance of reminders, searching and calling out, sighing, overactivity, crying

Answer 375

1. Accepting the reality of the loss e.g. come to terms with the person being 'gone'
2. Work through the pain of grief
3. Adjust to an environment in which the deceased is missing
4. Emotionally relocate the deceased and move on with life

Answer 376

- Closeness of relationship
- Meaningfulness of relationship
- Nature of relationship prior to death
- Expectedness and manner of death
- Age and developmental stage of griever
- Social support

Answer 377

Umbrella term that includes religious/faith frameworks, but it also includes the meaning of life, purpose, sense of personhood

Answer 378

- Belief in an afterlife - the continuing existence of the loved one and possibility of meeting up again
- Continued attachment - prayer as means of continuing connection with the deceased
- Defence against fear of personal death/extinction
- Religious funeral rituals that aid and progress the grief process
- Religious funeral rituals that recruit social support

Answer 379

- Extended grief reactions - getting stuck in one of the phases (normally each phase is about 6 months)
- Can be in denial for an extended period of time - exhibit mummification (not changing things in dead persons room for example)
- Major depressive disorders >2 months after loss

Answer 380

- Idea that psychotherapists will 'leak' their personal views regardless of their intention
- This will come across in their questioning/direction of questioning

Answer 381

Clinical decision support system - designed to aid clinician decision making

Answer 382

- Computerised
- Paper based
- Reminder systems
- Developed to aid with particular decisions

Answer 383

- Reminder systems - screening, vaccination, testing, medication use
- Decision systems (diagnosis and treatment) - model individual patient data against epidemiological data
- Prescribing - advice on drug and dosage, highlights potential drug interaction
- Condition management - Assists monitoring patients

Answer 384

- Reduced time to achieve therapeutic stabilisation
- Reduced risk of toxic drug level
- Reduced length of hospital stay
- Increased size of initial dose
- Increased serum drug concentration
- No change in adverse effects of drug

Answer 385

- Can improve practitioner performance in diagnosis, disease management, prescribing/drug dosing, rates of vaccination, screening, etc.
- Evidence for effects on patient outcomes not so robust

Answer 386

- Help patient understand probable outcomes of options
- Help patient consider the personal value they place on benefits vs harm
- Support patient in decision making
- Include additional information - on disease, costs, probability of outcomes, peoples opinions

Answer 387

No consensus on what information should be included in a patient decision aid

Answer 388

- Providing decisions 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

Answer 389

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

Answer 390

- Self-control of CDSS
- If clinical can notice help in practice

Answer 391

Diarrhoea and vomiting with or without pain

Answer 392

- Not cooking food thoroughly (particularly meat)
- Not correctly storing food that needs to be chilled
- Keeping cooked food unrefrigerated for a long period
- Eating food that has been touched by someone who is ill or has been in contact with someone with diarrhoea or vomiting
- Cross-contamination e.g. preparing raw meat on a chopping board then preparing salad on the same board

Answer 393

- Bacterial - salmonella, campylobacter, shigella, C. difficile
- Viral - norovirus, rotavirus
- Fungal - aspergillus
- Protozoal - cryptosporidia, giardia

Answer 394

- Bacterial toxins - clostridium perfringens, s. aureus, clostridium botulinum
- Marine biotoxins - scombroid poisoning, shellfish, ciguatera

Answer 395

- Heavy metals
- Pesticides
- Herbicides

Answer 396

Campylobacter

Answer 397

- Transmission - ingestion of contaminated food, faecal contaminations, person-person, infected animals
- Can cause enteric fever or enterocolitis
- Incubation period is 12-72 hours
- Symptoms - vomiting, diarrhoea, fever, headache, chills

Answer 398

- transmission - contaminated food by skin/nasal flora
- Produces enterotoxins
- Incubation - 24 hours
- Symptoms - rapid onset, projectile vomiting and diarrhoea

Answer 399

- Transmission - animal-human, person-person, contaminated water or land, associated with foreign travel
- Incubation - 2-5 days
- Symptoms - watery or mucoid diarrhoea, severe illness in immunocompromised

Answer 400

- Transmission - contaminated food, person-person
- Incubation - 1-6 days
- Symptoms - haemorrhagic colitis, 5% get haemolytic uraemic syndrome

Answer 401

- Transmission - faecal-oral route, environmental contamination, contaminated food and water
- Incubation - 24-48 hours
- Symptoms - nausea, projectile vomiting, low-grade fever, diarrhoea

Answer 402

- Transmission - contaminated cooked meat and poultry
- Incubation - 8-22 hours
- Symptoms - diarrhoea, abdominal pain

Answer 403

- Transmission - raw/undercooked meat, unpasteurised milk, bird-pecked milk, untreated water, domestic pets with diarrhoea, person-person
- Incubation - 2-5 days
- Symptoms - fever, headache, malaise, nausea, diarrhoea, vomiting is uncommon

Answer 404

- Isolation
- Hand hygiene
- Protection e.g. gloves, gowns, masks
- Environmental cleaning
- Respiratory hygiene and cough etiquette

Answer 405

Food that will not cause harm to a person who consumes the food when it is prepared, stored and/or eaten according to its intended use

Answer 406

- Food borne illness
- Nutritional adequacy
- Environmental contaminants
- Pesticides
- Naturally occurring contaminants
- Food additives

Answer 407

Allows exclusions from work of people that pose increased risk of GI infection spread - children in nursery/pre-school, people who work with food, health and social care staff, people with doubtful hygiene

Answer 408

- The sale of food that has been rendered injurious to health, is unfit for human consumption or is so contaminated that it would not be reasonable to expect it to be used for human consumption
- The sale of food which is not of the nature or substance or quality demanded by the purchaser
- The display of food for sale with a label which falsely describes the food, or is likely to mislead as to the nature or substance or quality of the food

Answer 409

- Analysis of the potential food hazards in a food business (e.g. microbiological, chemical & foreign matter contamination)
- Identification of the points in the operations where such hazards could occur
- Deciding which of the identified points are critical to food safety (critical points)
- Identifying and implementing effective control and monitoring procedures at the critical points
- Reviewing the hazards and critical points at periodic intervals and particularly when any change occurs to the operation

Answer 410

- Reduce the number of primary and secondary cases
- Reduce the harm consequent on the episode
- Prevent further outbreaks

Answer 411

- Preliminary phase - is there an outbreak? confirming the diagnosis, what is the nature and extent of the outbreak?
- Immediate steps - who is ill? how many? case finding; what is the cause? is proper care being arranged? what immediate action can be taken?

Answer 412

- Outliers are cases at the very beginning and end that may not appear to be related
- First check to make certain they are not due to a coding or data entry error

Answer 413

- Baseline level of illness
- Outbreak source
- A case exposed earlier than the others
- An unrelated case
- A case expose later than the others
- A case with a longer incubation period

Answer 414

- Compare food history of ill and well persons
- Point source outbreak - cohort study
- Common source of outbreak - case-control study

Answer 415

- Oesophageal - Middle East and Chine
- Gastric - Russia
- Colon - 'Western' countries, e.g. USA, UK

Answer 416

Fat intake

Answer 417

- Evidence from observational epidemiology that average fruit/veg intake of less than 200g associated with increased risk of cancer, but possibly little additional benefit beyond 400g/day
- Very little evidence that '5-a-day' have impact on cancer

Answer 418

- Beta carotene found in fruit/vegetables
- Cohort studies indicated protective relationship against cancer
- However RCT showed beta carotene increased risk of cancer
- Cohort groups had reduced risk due to confounding factors, e.g. increased exercise, reduced smoking, etc.

Answer 419

- Random error - diet varies and difficulties in measurement, people don't eat the same things everyday and individual consumptions vary significantly
- Homogeneity of exposure - if you only do your studies in the same types of populations they are likely to have similar environments and hence diets, so you are not able to apply results to the population
- Bias
- Confounding

Answer 420

- Food disappearance data
- Household survey - what do you buy and who eats what?
- Individual surgery - 24 hour recall, food frequency (very open to bias), diet diary, biomarkers (very rarely have this)

Answer 421

- Pros - captures usual diet and less work to code/complete
- Cons - don't record actual diet as eaten, overestimates fruit and vegetables, poor measure of energy intake, less flexible

Answer 422

- Pros - records diet as eaten (over limited period), better estimate of energy and absolute intake, more flexible
- Cons - required effort to complete and expensive to code

Answer 423

- Oesophageal - alcohol, obesity
- Stomach - possibly salted preserved foods
- Pancreas - overweight, obesity
- Hepatic - aflatoxin contamination
- Colorectal - preserved and red meat, alcohol, body fat
- Breast - alcohol, overweight
- Urologic - high calcium

Answer 424

- Per capita consumption in the UK is lower than many European countries
- however people in the UK start earlier and tend to drink more on single occasions ('binge drinking')
- Peak of consumption was 2008 - this is linked with affordability

Answer 425

- 38% of men and 16% of women (16-64) have an alcohol use disorder (approximately 8 million people)
- 21% of en and 9% of women are binge drinkers - double the recommended daily intake
- 3.6% of the total population are alcohol dependent (1.1 million people)

Answer 426

Delivered in a range of setting - primary and secondary care but also community setting (pharmacies, community health-oriented events)

Answer 427

- CBT - common
- Behavioural approaches - behavioural couples therapy, behavioural self-control for moderation goal
- Motivational interviewing
- Social behaviour and network therapy (SBNT)

Answer 428

- Alcoholic liver disease
- Alcoholic neuropathy
- Chronic pancreatitis
- Alcoholic cardiomyopathy
- Alcoholic gastritis
- Alcohol related accidents
- Risk factor for - colon cancer, mouth and oesophageal cancer, etc.

Answer 429

- Death - declining since 2008
- Crime and disorder
- Domestic violence - involved in 73% of cases
- Poor productivity at work
- Absences/sick leave from work
- Family effects - 5 million families deal with problem drinker, arguments, violence, debt, relationship problems

Answer 430

More effective policies:
- Price increases - taxation, minimum price
- Restricting availability - opening times, reducing outlet density, age restrictions

Moderatley effective policies:
- Restricting exposure of young people to adverts
- Treatment - identification and brief advice

Less effective policies:
- Drug and alcohol education
- Mass media campaigns

Answer 431

- Home office (focus on public disorder)
- Department of health (focus on public health)

Answer 432

- Minimum unit price policy dropped, multi-buy promotion offers were not banned as suggested
- Local health bodies able to instigate review of licenses
- Double fine for selling alcohol to underage people
- 'Enforced sobriety' - 1 year pilots based on US models
- Overview alcohol consumption guidelines for adults
- Alcohol included in NHS health check for adults 40-75

Answer 433

- Target resources to those activities that give the greatest health gain for the money spent as this will maximise population health gain for the money spent as this will maximise population health gain
- Informing these choices required estimation of value of what is given up when a patient is treated (opportunity cost) and the value of what is gained in terms of improvements in the health of patients

Answer 434

Investing in healthcare are interventions that are worthwhile

Answer 435

Investing in health care interventions which make the best use of scarce resources

Answer 436

- Geographic allocation of funding by weighted capitation
- Resourcing determined by population weighted by need

Answer 437

Evidence of social class equality in the use of primary care and social class inequality in the use of secondary care

Answer 438

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

Answer 439

- Incremental investments in an activity may be associated with diminishing returns
- i.e. successive increase in activity (inputs) yield declining benefits to the patient, or the more you do, the less they benefit

Answer 440

- Values both inputs (opportunity costs) and outputs (health outcomes) of any intervention
- Assess if changes in resource allocation are efficient
- Important because increasing healthcare expenditure needs best outcome for the money e.g. NICE

Answer 441

- Cost to NHS - NICE perspective, cost of drug, cost of delivery
- Cost to patient, carers, and society - lost working days

Answer 442

Health gain = increase in length + QoL

Answer 443

Chooses cheapest option between treatments that have identical outcomes

Answer 444

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

Answer 445

- Combines multiple 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

Answer 446

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

Answer 447

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

Answer 448

- Macro (societal) level - regarding health funding vs education or funding of certain drugs
- Micro (clinical) level - individual decisions regarding care of individual patients

Answer 449

- For - treatment and care of elderly people is very costly so 'cost-effective' argument might require resources elsewhere
- Against - most of the elderly burden relates to cost of illness and incapacity rather than age, young person with chronic/serious disease could also cost the same amount

Answer 450

- Older people had a long life already, therefore fairer to divert resources to younger people
- Elderly also have a disproportionate share of the available resources allocated to them

Answer 451

- treating on the basis of need might mean older people don't receive lower priority
- Years of life saves 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. equals treatment

Answer 452

- For - 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
- Against - 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

Answer 453

Unjustifiable difference in treatment based solely on age

Answer 454

- Direct - direct difference in treatment based on age, cannot be justified
- Indirect - neutral provision or practice that has harmful repercussions on a person based on their age

Answer 455

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

Answer 456

- 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

EXAMPLE:
0.5 QALY points x 5 years = 2.5 QALYs
0.8 QALY points x 5 years = 4.0 QALYs

Answer 457

QALYs focus on overall likely outcomes of resource allocations

Answer 458

- Low - high priority, efficient health care
- High - low priority

Answer 459

- 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

Answer 460

- Difficulties in measuring - how do you measure quality or value or life? who makes the decisions? introduces bias
- Can seem unjust - can favour life years over individual lives

Answer 461

- 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)

Answer 462

Population
Intervention
Comparison
Outcome

Answer 463

- Are the results of the study valid?
- What are the results?
- Can I apply the results to this patient's care?

Answer 464

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

Answer 465

- 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 ratio)
- Harm/aetiology - look at relative risk, odds ratio, number needed to harm

Answer 466

- How similar are the patients to the study to your patient?
- Can the local healths service provide the intervention/diagnostic test?
- What are the benefits and costs?