Health and Society year 2 cards

Question 1

What is evidence-based decision making (EBDM)?

Answer 1

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

Question 2

What does EBDM involve? (4 key aspects)

Answer 2

• patient preferences
• available resources
• research evidence
• clinical expertise

Question 3

Why is decision making in medicine important?

Answer 3

• doctors make decisions constantly
• the decisions have an effect on patients, families and society
• having an understanding of decision making, and the role of evidence, can help improve medical practice

Question 4

Why do we need EBDM?

Answer 4

• limited time to read
• inadequacy of ‘traditional’ sources of information - textbooks are often out of date
• disparity between diagnostic skills/clinical judgment (which increase over time) and up-to-date knowledge and clinical performance (which decrease over time)

Question 5

What are the different types of research studies and when are they each appropriate? (6 main types)

Answer 5

> cohort studies - prognosis, cause
case-control studies - cause
randomised control trials - treatment interventions, benefit and harm, cost effectiveness
qualitative approaches - patient and/or practitioner perspectives
diagnostic and screening studies - identification
systematic reviews - summary of evidence for a specific question

Question 6

What is the process of EBDM? (5 steps)

Answer 6

1. Converting the need for information into an answerable question
2. identifying the best evidence to answer that question
3. critically appraising the evidence for its validity, impact and applicability
4. Integrating the critical appraisal with clinical expertise and the patients unique circumstances
5. evaluating our effectiveness and efficiency in carrying out the previous steps and seeking ways to improve

Question 7

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

Answer 7

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

Question 8

What is antibiotic resistance?

Answer 8

Bacteria change so antibiotics no longer work in people who need them to treat infections

Question 9

What are the reasons for the widespread use of antibiotics? (2 reasons)

Answer 9

• increased global availability
• uncontrolled sale in many low or middle income countries

Question 10

What are some of the causes of antibiotic resistance? (5 causes)

Answer 10

• use in livestock for growth promotion
• releasing antibiotics into environment during pharmaceutical manufacturing
• volume of antibiotics prescribed
• missing doses when taking antibiotics
• inappropriate prescribing of antibiotics

Question 11

How can antibiotic resistance be prevented? (5 ways)

Answer 11

• using antibiotics only when prescribed by doctor
• completing the full prescription
• never sharing antibiotics or using leftover prescriptions
• only prescribing antibiotics when they are needed
• using the right antibiotic to treat the illness

Question 12

Which factors influence infection? (5 main factors)

Answer 12

> infectious agents - ability to reproduce, survival, spread, infectivity, pathogenicity
environment - contamination, other humans, animals, water
mode of transmission - droplet, airbourne, aerosol, direct consumption, fecal-oral route, blood-bourne, sexual contact, zoonosis
portal of entry - mouth, nose, ears, genital tract, skin, urinary tract
host factors - chronic illness, nutrition, age, immunity, lifestyle (e.g. smoking, drugs etc. )

Question 13

What are the most important infectious diseases in the UK? (9 diseases)

Answer 13

• diphtheria
• haemophilus influenzae
• measles
• mumps
• rubella
• poliomyelitis
• pneumoccocal disease
• tetanus
• whooping cough

Question 14

What are the most important infectious diseases in developing countries? (4 diseases)

Answer 14

• pneumonia
• chronic diarrhoea (due to several causes)
• malaria
• HIV/AIDs

Question 15

What is surveillance?

Answer 15

Systematic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken

Question 16

What is the purpose of surveillance? (3 main points)

Answer 16

• serve as an early warning system for impending public health emergencies
• document the impact of an intervention, or track progress towards specific goals
• monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategy

Question 17

Which infectious disease are becoming more common in the UK and why?

Answer 17

Hospital acquired infections (e.g. MRSA, STIs, mumps)

Question 18

Which infectious diseases are associated with exposure to healthcare?

Answer 18

> nosocomial infections
more common examples (60%) - UITs, pneumonia, lower respiratory tract infections (LRTIs), septicaemia
less common examples (40%) but more dangerous - chicken pox, TB, legionella, MRSA

Question 19

What can be done to reduce the risk of nosocomial infections? (3 main steps)

Answer 19

> prevention - hand washing, infection control programmes, advisory service, surveillance (mandatory for MRSA), sterilisation and decontamination of instruments
detection, investigation and control of outbreaks - screening, barrier nursing/isolation of infected patients, sharps disposal
policies and procedures to prevent and control infection - dissemination and implementation of policies, education and training, monitor clinical practice

Question 20

What is global health?

Answer 20

• the health of the global population
• improving health and achieving equality for all people worldwide
• emphasis on trans-national issues, determinants and solutions

Question 21

What is international health?

Answer 21

Health defined by geography (nation wealth), problems (e.g. infections, water sanitation), instruments (e.g. infection control aid), and a recipient and donor relationship

Question 22

What are the major functions of global health? (4 key points)

Answer 22

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

Question 23

What is the motivation for global health? (2 key aspects)

Answer 23

• increased awareness of global health disputes
• enthusiasm to make a difference across international boundaries

Question 24

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

Answer 24

Less than 10% of worldwide resources devoted to health research were put towards health in developing countries, where over 90% of all preventable deaths worldwide occurred

Question 25

What is the solution for the ‘90/10 gap’? (4 steps)

Answer 25

> regulation of the quality of imported foods, medicines, manufactured goods, and inputs
getting timely access to information about the global spread of infectious disease
procurement of sufficient vaccine and drug supplies in a pandemic
ensuring a sufficient corps of well trained health personell

Question 26

What impact has travel and migration had on diseases seen in the UK? (5 impacts)

Answer 26

• help spread infectious diseases
• transmission of behaviour and cultures increases risk of non-communicable diseases
• may introduce a disease to a new population - widespread and deadly effects
• more in contact with animals - zoonosis
• migrants may bring diseases to countries that have not been exposed

Question 27

What is WHOs definition of environment, in relation to health?

Answer 27

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

Question 28

What is an outbreak?

Answer 28

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

Question 29

What is an epidemic?

Answer 29

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

Question 30

What is a pandemic?

Answer 30

Worldwide epidemic (outbreak -> epidemic -> pandemic)

Question 31

How can we prevent epidemics? (5 steps)

Answer 31

1. insure developing countries against threat of pandemic
2. funds and international responders sent to countries with outbreak to reduce human suffering
3. development of vaccines
4. fast, early, planned response means less spread
5. monitor disease and prevent outbreaks

Question 32

What is the role of WHO in public health? (6 key aspects)

Answer 32

1. provide leadership on matters critical to health and engaging in partnerships where joint action is needed
2. shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge
3. setting norms and standards and promoting and monitoring their implementation
4. articulating ethical and evidence based policy options
5. provide technical support, catalysing change and building sustainable institutional capacity
6. monitoring the health situation and assessing health trends

Question 33

What general intervention strategies are possible for HIV/AIDS? (6 strategies)

Answer 33

• 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 safe sex behaviour at the population level
• diagnosis and treatment of STDs
• HIV voluntary counselling and testing

Question 34

What are the determinants of effective outcomes of intervention? (3 main determinants)

Answer 34

> economics - many developing countries can only spend few dollars per annum per capita on healthcare
priorities - ‘developed world academic’ analyses of cost-effectiveness may not reflect 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

Question 35

What are the current problems and issues?

Answer 35

• Africa struggles against debt, trade restrictions and inadequate aid provision
• global funds ar over-resourced
• US politics are retrogressive and harmful

Question 36

What are the public health objectives of vaccination? (7 objectives)

Answer 36

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

Question 37

What are the 2 most effective developments in healthcare to protect population health?

Answer 37

• clean drinking water
• vaccination

Question 38

What factors influence the utility of immunisation/vaccination as an approach to disease prevention? (9 points)

Answer 38

• disease burden
• risk of exposure to 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

Question 39

What is required for a disease to be eradicate using vaccination? (3 requirements)

Answer 39

• where no other reservoirs of infection exist in animals or environment
• where consequences of infection are very high
• where scientific and political prioritisation exist

Question 40

Give examples of diseases that have been eradicated

Answer 40

• small pox
  -polio

Question 41

What is herd immunity?

Answer 41

level of immunity of population which protects the whole population
- herd immunity only applies to disease that are passed from person to person
- provides indirect protection to unvaccinated as well as direct effect on those to be vaccinated
- a disease can therefore be eradicated even if some people remain susceptible

Question 42

What is R0?

Answer 42

• basic reproduction rate
• the average number of individuals directly infected by an infectious case during the infectious period, in a totally susceptible population

Question 43

What factors affect R0? (3 main factors)

Answer 43

• the rate of contacts of host population
• the probability of infection being transmitted during contact
• the duration of infectiousness

Question 44

What is effective reproduction rate (R)?

Answer 44

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

Question 45

What is the equation for effective reproduction rate?

Answer 45

R = R0x (x is the fraction of the host population which is susceptible e.g. half population is 0.5)

Question 46

What is the equation for herd immunity?

Answer 46

H = (R0 -1) / R0

Question 47

What is a susceptible population? (4 key points)

Answer 47

• 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 disease 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 the vaccine is contraindicated for them

Question 48

What is WHOs role in vaccination?

Answer 48

• makes recommendations for countries on vaccination policy
• supports less able countries with vaccine strategy implementation
• works through international health regulations to ensure the maximum security against the international spread of disease with minimum interference with global traffic

Question 49

List some international immunisation programmes

Answer 49

• expanded programme on immunisation (EPI)
• global polio eradication initiative (GPEI)
• global alliance for vaccines and immunisation (GAVI)

Question 50

How are new vaccination programmes implemented? (who, how and when)

Answer 50

> who - to protect the vulnerable, contain outbreak, eradicate disease
how - pilots, phased introduction, global vaccination
when - greatest impact on disease burden

Question 51

What is shared decision making and why is it important?

Answer 51

• conversation between patient and their healthcare professional to reach a health choice together
• important when - there is more than one reasonable option, no one has a clear advantage, the possible benefits/harm of each option affects patient differently

Question 52

What are the pros of vaccination? (8 points)

Answer 52

+ can save lives
+ ingredients are safe in the amounts used
+ adverse reactions are rare
+ herd immunity
+ save children and parents time and money
+protects future generations
+ eradication of disease
+ economic benefit for society

Question 53

What are the cons of vaccination? (7 points)

Answer 53

• can cause serious and sometimes fatal side effects
• contain harmful ingredients
• government shouldn’t intervene in personal medical choices
• can contain some ingredients people object (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. rota virus)

Question 54

What factors influence decision making? (6 factors)

Answer 54

• lifestyle
• perception about health
• beliefs about childhood diseases
• risk perception of these diseases
• perceptions about vaccine effectiveness and components
• trust in the institution

Question 55

What is the population vs individual interest debate?

Answer 55

• 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

Question 56

Which websites can be used to find out if a person needs travel vaccines?

Answer 56

NHS fitfortravel
The national travel health network and centre (naTHNaC)

Question 57

What are some of the free and private travel vaccines available?

Answer 57

free - diphtheria, polio, tetanus, typhoid, hepatitis A, cholera
private - hepatits B, japanese encephalitis, meningitis, rabies, TB, yellow fever

Question 58

What factors should be consider when deciding to get travel vaccinations? (8 factors)

Answer 58

• The country or countries you’re visiting
• when you are travelling
• where you’re staying
• how long you’ll be staying
• your age and health
• what you’ll be doing during the stay
• if you’re working as an aid worker
• if you’re working in a medical setting
• if you’re in contact with animals

Question 59

What are the 5 common cancers (incidence) in adult men and women in the UK (list in order)?

Answer 59

1. Breast/prostate
2. lung
3. bowel
4. melanoma
5. non-hodgkin lymphoma

Question 60

What are the 5 most common causes of cancer mortality for adult men and women combined in the UK (list in order)?

Answer 60

1. Lung
2. bowel
3. prostate/breast
4. pancreas
5. oesophagus

Question 61

What are the most common cancers in children?

Answer 61

Leukaemias

Question 62

What is the most common causes of cancer mortality in children?

Answer 62

Brain, CNS and intracranial tumours

Question 63

How do the patterns of cancer in the UK differ from that seen in a developing country?

Answer 63

Mortality is higher in UK (29%)

Question 64

What is the role of legal and lifestyle changes in reducing incidence and mortality of cancer? (3 main points)

Answer 64

• prevention - legal and lifestyle changes, vaccinations
• screening - early detection and diagnosis
• disease management - improving treatments and quality of life

Question 65

What is meant by difficult (bad) news?

Answer 65

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

Question 66

What factors can affect the impact of news on a patient? (7 factors)

Answer 66

• institutionalised beliefs
• personality types
• gender
• culture/race
• religion
• patients knowledge
• relatives

Question 67

What anxieties might health care professionals have about breaking bad news? (5 points)

Answer 67

• Uncertainty about the patient’s expectations
• fear of destroying patients hope
• fear of their own inadequacy in the face of controlling disease
• not feeling prepared to manage patients anticipated emotional reactions
• embarrassed at having previously painted too optimistic a picture for the patient

Question 68

What is the ABCDE method of breaking bad news?

Answer 68

A - Advanced preparation
B- building a relationship
C - communicate well
D - deal with patient reactions
E - encourage and validate emotions

Question 69

What is the SPIKES method of breaking bad news?

Answer 69

S - Setting up
P - perception
I - intervention
K - knowledge
E - emotions
S - summary and srategy

Question 70

What emotions may a patient feel when they receive difficult news? (5 main emotions)

Answer 70

• grief
• distress
• denial
• anger
• agitation/restlessness

Question 71

How can cancer change partner relationships? (6 changes)

Answer 71

• change in roles
• change in responsibilities
• change in physical needs
• change in emotional needs
• change in sexuality and intimacy
• change in future plans

Question 72

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

Answer 72

• 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 medical officer in 1995 which generated the calaman-hine report

Question 73

What were the conclusions and consequences of the Calman-Hine report (1995)? (6 points)

Answer 73

(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 have access to a uniformly high quality of care
- public and professional education to realise the early symptoms of cancer
- patients, families and carers should be given clear information about treatment options and outcomes
- the development of cancer centres should be patient centred
- primary care to be central to cancer care
- the psychosocial needs of cancer sufferers and carers can be recognised

Question 74

What are the Calman-Hine solutions?

Answer 74

There should be 3 levels of care:
> primary care
> cancer units serving district general hospitals - treat common cancers, diagnostic procedures, common surgery, non complex chemo
> cancer centres (populations in excess of 1 million) - treat rare cancers, radiotherapy, complex chemo

• key to managing patients would be the MDT

Question 75

What is a national service framework? (3 main points)

Answer 75

> setting 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

Question 76

What are the main aims of the NHS cancer plan (2000)?

Answer 76

> 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 and preparation for genetics revolution

plan is followed by several improving outcomes guidance (NICE) relating to the delivery of cancer treatment including the provisions of chemotherapy, radiotherapy etc.

Question 77

What are the 6 key areas for action in the cancer reform strategy (2007)?

Answer 77

1. prevention - smoking, obesity, alcohol etc.
2. screening - diagnosing cancer earlier
3. ensuring better treatment - reduced waiting times, increase radiotherapy capacity, new drugs referred to NICE, chemotherapy audits
4. living with and beyond cancer - National cancer survivorship initiative
5. reducing cancer inequalities
6. delivering care in the most appropriate setting - locally where possible, services should be centralised where necessary

Question 78

Which cancers are screened for?

Answer 78

• cervical
• breast
• bowel

Question 79

What is the national cancer survivorship initiative?

Answer 79

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

Question 80

What were the main outcomes from ‘Improving outcomes: A strategy for cancer (2011)’? (4 outcomes)

Answer 80

1. prevention and early diagnosis - focus on lifestyle, screening, diagnostic tests
2. quality of life and patient experiences - patient experience surveys, more 1:1 support roles, risky stratified pathway of care, following assessment and care planning
3. better treatments - cancer drug fund, reducing variation in radiotherapy, reaffirmed MDTs, national audits
4. reducing inequalities

Question 81

What are some of the inequalities experiences amongst cancer patients? (5 examples)

Answer 81

> 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 than people with more common forms of cancer

Question 82

What are the outcomes from the independent cancer Taskforce (2015)? (6 outcomes)

Answer 82

1. spearhead a radical upgrade in prevention and public health
2. drive a national ambition to achieve earlier diagnosis
3. establish patient experiences being on a par with clinical effectiveness and safety
4. transform our approach to support people living with and beyond cancer
5. make the necessary investments required to deliver a modern high quality service
6. overall process for commission, accountability and provision

Question 83

What is body image?

Answer 83

• Perceptions, thoughts, and behaviours related to one’s appearance

Question 84

What is biographical distribution?

Answer 84

• the destabilisation and questioning of identity and biography
• can call into question the past, future, sense of I and where I am going

Question 85

Give examples of diseases/symptoms/treatments/side-effects which affect body image (6 examples)

Answer 85

• scars
• prosthetic device e.g. leg
• mastectomy
• impact on sexuality/function/pain/appearance
• stoma
• hairloss
• weightloss/gain

Question 86

What is the importance of hair?

Answer 86

• important site for individual and group identity
• 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)

Question 87

What are the functions of the clinical record? (4 points)

Answer 87

• support patient care
• improve future patient care
• social purposes at the request of patients
• medicolegal document

Question 88

What should be recorded in a clinical record? (7 key aspects)

Answer 88

1. presenting symptoms and reasons for seeking health care
2. relevant clinical findings
3. diagnosis and important differentials
4. options for care and treatment
5. risks and benefits of care and treatment
6. decisions about care and treatment
7. action taking and outcome

Question 89

What are the differences between paper and electronic records?

Answer 89

paper:
- continuous, portable, writer identified, legibility issues, must be dated and signed
electronic:
- problem orientated, searchable, structured, safer prerscribing, clinical decision support software

Question 90

What is the use of records in audit, research and management?

Answer 90

• support clinical audit
• facilitates clinical governance
• facilitates risk management
• support clinical research

Question 91

What is duty of care?

Answer 91

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

Question 92

What is negligence?

Answer 92

• failure to exercise the care that a reasonably prudent person would exercise in like circumstances
• you have to make decisions that adhere to your duty of care as a doctor and could not be considered negligent

Question 93

What are the 4 ethical principles?

Answer 93

-autonomy
- beneficence
- justice
- non-maleficence

Question 94

What are the ethical theories? (3 main theories)

Answer 94

> consequentialism/utilitarianism - correct moral response is related to the outcome or consequence of the act
deontology - places value on the intention of the individual and focuses on roles, obligations and duties
virtue ethics - right living is derived from the moral character of the agent

Question 95

How do you evaluate an argument? (2 steps)

Answer 95

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

Question 96

Why might an argument be invalid? (4 reasons)

Answer 96

1. different premises may express different concepts
2. confusing necessary with sufficient and vice versa
3. insensitive to the way in which claims are qualified
4. argument begs the question

Question 97

Why might an argument be unsound? (3 reasons)

Answer 97

1. argument is invalid
2. argument is valid but one or more premise is false - makes a false/controversial moral/imperial claim
3. an unsound argument doesn’t mean there will be an unsound conclusion

Question 98

What should be avoided in arguments? (5 points)

Answer 98

1. Straw man fallacy - simply ignoring the person’s actual position and substituting it for a distorted, exaggerated or misrepresented version of that position
2. Ab hominen - directed against a person rather than the position they are maintaining
3. appealing to emotion
4. begging the question
5. argument from fallacy - conclusion must be false because the premises are false (not neccesarily)

Question 99

What is a moral argument?

Answer 99

• seek to support a moral claim of some kind
• arguments need not succeed but to be an argument it must at least provide support and reasons for the claim and question

Question 100

What is a deductive argument?

Answer 100

purely logic “this means this, therefore this means this”

Question 101

What is an inductive argument?

Answer 101

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

Question 102

What are MDTs in cancer care and why are they needed?

Answer 102

• modern management of cancer - involves many disciplines, surgical and non-surgical, oncology
• allied health professionals e.g. nurses, physios, speech therapist etc.
• delivery of cancer care is often fragmented over multiple hospital sites - need to streamline and coordinate various components of care
• probably better outcomes for patients managed in MDTs

Question 103

Who is in a cancer MDT (core and extended)?

Answer 103

Core (medical staff):
- physicians
- surgeons
- oncologists
- radiologists
- histopathologists
- specialist nurses
- MDT coordinator

extended:
- physios
- dietician
- palliative care
- chaplin

Question 104

What are the functions of MDTs in cancer care? (6 key functions)

Answer 104

1. discuss every new diagnosis of cancer within their site
2. decide on a management plan for every patient
3. inform primary care of that plan
4. designate a key worker for that patient
5. develop referral, diagnosis and treatment guidelines for their tumour sites
6. audit

Question 105

What is sensitivity?

Answer 105

• True positives
• measures the proportion of positives that are correctly identified

Question 106

What is the equation for sensitivity?

Answer 106

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

Question 107

What is specificity?

Answer 107

• True negatives
• measures the proportion of negatives that are correctly identified

Question 108

What is the equation for specificity?

Answer 108

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

Question 109

What is a diagnostic test?

Answer 109

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

Question 110

What are the uses of diagnostic tests? (4 uses)

Answer 110

1. diagnosis
2. monitoring
3. screening
4. prognosis

Question 111

How is sensitivity and specificity important in informing diagnosis?

Answer 111

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

Question 112

What does true positive mean?

Answer 112

Test indicates disease when there is disease

Question 113

What does true negative mean?

Answer 113

Test indicates no disease when there is no disease

Question 114

What does false positive mean?

Answer 114

Test indicates disease when there is no disease

Question 115

What does false negative mean?

Answer 115

Test indicates no disease when there is disease

Question 116

What is positive predictive value?

Answer 116

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

Question 117

What is negative predictive value?

Answer 117

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

Question 118

What is the likelihood ratio?

Answer 118

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

Question 119

What is screening?

Answer 119

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

Question 120

What is the purpose of screening? (3 purposes)

Answer 120

1. opportunities for primary prevention are limited
2. opportunities for treatment are limited
3. screening gives potential for earlier and more effective treatment

Question 121

What is commonly screened for? (8 examples)

Answer 121

1. cancer - colorectal, breast, cervical
2. PPD test - tuberculosis
3. prenatal test - foetal abnormalities
4. new born blood spot test - PKU, cystic fibrosis, etc.
5. ophthalmoscopy or digital photography and image grading - diabetic retinopathy
6. ultrasound scan - AAA
7. screening for metabolic sydnrome
8. screening for potential hearing loss in newborns

Question 122

What are the limitations of screening?

Answer 122

> 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 false positive result
unnecessary investigation and treatment of false positive results
stress and anxiety caused by prolonged knowledge of an illness without any improvement of an outcome
false sense of security caused by false negatives which may delay final diagnosis

Question 123

What are the pros and cons of good screening?

Answer 123

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

cons - some people get tests, diagnosis and treatment with no benefit; some people get ill or die despite having a negative screening test

Question 124

What areas should be evaluated when deciding what should be screened for? (4 areas)

Answer 124

• 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, opppourtunity cost, quality assurance

Question 125

What is sojourn time?

Answer 125

the duration of a disease before clinical symptoms become apart, but during which it is detectable by a screening test
- its clinical relevance is that it represents the duration of the temporal window of oppourtunity for early detection
- length of sojourn time = short-rapidly progressive disease, poorer prognosis
- length of sojourn time = long = better prognosis

Question 126

What is length bias?

Answer 126

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

Question 127

What are the consequences of length bias?

Answer 127

• Diseases with a longer sojourn time are ‘easier to catch’ in the screening net
• on average individuals with diseases detected through screening automatiically have a better prognosis than people who present with symptoms/signs
• if we simply compare individuals who choose to be screened with those who dont we get a distorted picture

Question 128

What is lead time bias?

Answer 128

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

Question 129

What are the consequences of lead time bias?

Answer 129

• 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

Question 130

What is over diagnosis bias?

Answer 130

overestimation of survival duration amongst screen detected cases caused by inclusion of pseudo disease - sub clinical disease that wouldn’t become overt before the patient dies of other cause
- occurs when screen detected cancer are either non-growing or so slow growing that they never would cause medical problems

Question 131

What is PSA testing and what can cause elevated PSA?

Answer 131

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

Question 132

What are the advantages of PSA screening?

Answer 132

+ can help detect tumours with no symptoms
+ allows estimation of prostate size and stage
+ helps doctors predict response to treatment
+ can be used to monitor men who are at increased risk

Question 133

What are the disadvantages of PSA screening?

Answer 133

• 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

Question 134

What are some of the impacts of incontinence on a patient?

Answer 134

• distress
• embarrassment
• inconvenience
• threat to self esteem
• loss of personal control
• desire for normalisation
• loss of interest in sex
• difficulty sleeping (especially with nocturia)

Question 135

What impact might chronic dialysis have on a patient?

Answer 135

• regular hospital admissions
• restriction of leisure time
• may have to give up job
• increased dependence on dialysis
• uncertainty about future
• fatigue
• limitations of liquids and foods
• disrupts family and friend relationships
• depression
• lower self esteem

Question 136

What 4 sources are used when making a clinical decision?

Answer 136

1. patient preferences
2. available resources
3. research evidence
4. clinical expertise

Question 137

What is opportunity cost?

Answer 137

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

Question 138

What is distributive justice?

Answer 138

How we distribute resources the are finite in a fair way

Question 139

How can you decide ways to distribute healthcare? (5 factors)

Answer 139

1. QALY calculation
2. waiting list
3. likelyhood of complying with treatment
4. lifestyle choices of patient
5. ability to pay

Question 140

What is confidentiality?

Answer 140

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

Question 141

Why is it important to maintain confidentiality? (6 points)

Answer 141

1. improves trust between patient and doctor
2. respects autonomy
3. prevents patient harm
4. virtuous
5. human rights act
6. GMC requirements

Question 142

When can confidentiality be breached?

Answer 142

• statute (law)
• consent by patient
• public best interest

Question 143

Name some statutes (laws) that oblige doctors to disclose information

Answer 143

• Public Health Act 1984
• road traffic act 1988
• prevention of terrorism act 1989

Question 144

Define patient safety

Answer 144

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

Question 145

What is an adverse event/

Answer 145

Unintended event resulting from clinical care and causing patient harm

Question 146

What is a near miss?

Answer 146

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

Question 147

Describe the Swiss cheese model of accident causation

Answer 147

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

Question 148

What are the main causes of error at an individual and a system level?

Answer 148

individual error - errors of individuals, blames individual for forgetfullness, intention or moral weakness

system error - conditions under which an individual works, tries to build defences to eliminate errors or mitigate their effect

Question 149

What are active failures?

Answer 149

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

Question 150

What is latent error?

Answer 150

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

Question 151

What are the different types of errors? (3 types)

Answer 151

1. knowledge based - such as forming wrong intentions or plans as a result of inadequate knowledge/experience
2. rule based - encounter relatively familiar problems but imply wrong rule, either misapplication of a good rule or application of a bad rule
3. 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 interuption or distraction

Question 152

What are violations?

Answer 152

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

Question 153

What are the types of violation? (4 types)

Answer 153

• 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 reasoning for making (e.g. time constraints, may be in patients best interests)
• reckless - deliberate deviations from a protocol/code of conduct and include acts where oppourtunity for harm is forseeable and ignored, although harm may never be intended
• malicious - deliberate deviations from a protocol/code of conduct, where the intention is to cause harm

Question 154

What systems are in place in the NHS to try and prevent errors occurring? (3 systems)

Answer 154

• 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 incidence including near misses; all trust 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, health care 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

Question 155

How do we know if a hospital is safe?

Answer 155

hospital mortality data
- data on other measures of safety - reports of never events and serious incidents, NHS safety thermometer, patient safety dashboards
- monitoring and inspections by regulators - care quality commission (CQC), NHS improvement

Question 156

What situations are associated with an increased risk of error? (6 examples)

Answer 156

1. unfamiliarity with the task
2. inexperience
3. shortage of time
4. inadequate checking
5. poor procedures
6. poor human equipment interface

Question 157

What should we do when adverse incidents occur? (5 steps)

Answer 157

1. should report it - incident reporting systems
2. assess its seriousness
3. analyse why it occurred - route case analysis
4. be open and honest with the affect patient and apologise - duty of candour
5. learn from the event and put in place action to reduce risk of repeat

Question 158

Why do children go to A&E?

Answer 158

• accident
• injury
• asthma
• respiratory illness
• infective process
• rashes
• appendicitis

Question 159

Why are males more likely to die than females?

Answer 159

• higher suicide rates
• violence related incidents
• road traffic accidents
• behavioural differences between males and females- more likely to take part in risky behaviour

Question 160

What is the most common cause of external deaths in adolescents?

Answer 160

Traffic accidents (>50%)

Question 161

Why does poverty increase the chance of getting ill?

Answer 161

• poor nutrition
• overcrowding
• lack of clean water
• harsh realities that may make putting your health at risk
• the only way to survive or keeping your family safe

Question 162

Why does poor health increase poverty?

Answer 162

• Reducing a family’s work productivity
• leading family to sell assets to cover the cost of treatment

Question 163

What are the implications of chronic illness in children?

Answer 163

• effects physical, metal and social development
• repeated absence at school
• effect on parents and siblings
• financial effect (family and community)
• can be lifelong

Question 164

What conditions are screened for before birth? (3 main tests)

Answer 164

Antenatal screening tests identify major abnormalities
1. alpha feto protein - raised in neural tube defects and some GI abnormalities
2. downs test - alpha feto protein and HCG
3. ultrasound growth check, cardiac abnormalities, diaphragmatic hernia

Question 165

What tests are done neonatally? (2 tests)

Answer 165

1. blood spot test - PKU, cystic fibrosis, sickle cell disease, congential hypothyroidism
2. physical examination

Question 166

What are the timings for screening and developmental surveillance?

Answer 166

• 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

Question 167

What is the purpose of the 6-8 week postnatal check?

Answer 167

• 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 and eyes
• health promotion - immunisations, breast feeding, reducing risk of SIDS, car safety
• assessment of parenting and emotional attachment

Question 168

What is looked for in the heart examination at the 6-8 week postnatal check?

Answer 168

• look for cyanosis, ventricular heave, respiratory distress, tachypnea
• feel apex beat
• listen for murmurs

Question 169

What is developmental dysplasia of hip (DDH)?

Answer 169

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

Question 170

What are the tests for developmental dysplasia of hip (DDH)?

Answer 170

> Barlow’s 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

Question 171

What are the normal vital signs of a healthy baby?

Answer 171

• Respiratory rate - 30-60 breaths per minute
• heart rate 100-160 bpm
• temperature - 37 degrees celcius

Question 172

What immunisations should be given in the first year of life?

Answer 172

• 8 weeks - 6-in-1 vaccine (1st dose), rotavirus vaccine (1st dose), MenB vaccine (1st dose)
• 12 weeks - 6in1 vaccine (2nd dose), pneumococcal (PCV vaccine), rotavirus vaccine (2nd dose)
• 16 weeks - 6in1 vaccine (3rd dose), MenB vaccine (2nd dose)
• 1 year - hep/men C vaccine (1st dose), MMR (1st dose), PCV vaccine(2nd dose), Men B (3rd dose)

Question 173

What is puerperium?

Answer 173

post natal period
- period of around 6-8 weeks after child birth, during which the mothers reproductive organs return to their original non pregnant condition

Question 174

What are the main aims of antenatal care? (6 aims)

Answer 174

1. monitor progress of pregnancy to optimise maternal and foetal health
2. develop and partnership between the mother and health professionals
3. exchange info that promotes choice - about lifestyle, location of birth etc.
4. recognise deviations from the norm and refer appropriately
5. provide oppourtunites to provide for birth and parenthood
6. increased understanding of public health issues

Question 175

Which key documents influence antenatal care provisions?

Answer 175

• 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 birth’

Question 176

What were the key themes of the national maternity review ‘Better births’? (7 themes)

Answer 176

1. personalised care
2. continuity of care
3. safer care
4. better postnatal and perinatal mental health care
5. multiprofessional working
6. working across boundaries
7. a fairer payment system

Question 177

What tests are done at antenatal visits? (3 main tests)

Answer 177

1. physical examination - weight, BP, urialysis
2. blood tests - FBC, antibodies, ABO and Rh, HIV
3. psychosocial and emotional support - general wellbeing, work, financial, anxiety

Question 178

What are some of the risk factors for adverse outcomes to pregnancy?

Answer 178

> chronic or acute disease - maybe complicated with pregnancy
proteinuria - could indicate renal pathology
significant increased BP readings - preeclampsia, 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 or still birth
social or psychological factor - mental health problems can lead to antenatal/postnatal depression

Question 179

What are the different forms of pregnancy loss? (4 types)

Answer 179

• Spontaneous miscarriage - loss of pregnancy before 24 completed weeks of pregnancy
• ectopic pregnacy - fertilised ovum implants outside uterus (embyo grows inside fallopian tube or even abdomen)
• termination of pregnancy
• still birth - born after 24 weeks and doesn’t show any sign of life

Question 180

What is the MBRRACE-UK report (2014)?

Answer 180

mother and babies reducing risk through audits and confidential enquiries across the UK
- looked at standards of care, mortality and morbidity rates
- 1/3 of mothers died from medical and mental health problems
- 3/4 of women who died had no mental health problems before they died

Question 181

What are common causes of death in the postnatal period? (4 causes)

Answer 181

1. infection
2. haemorrhage
3. thrombosis
4. hypertensive disorders (eclampsia)

Question 182

What physical health and wellbeing issues might a woman experience in the postnatal period? (9 examples)

Answer 182

1. perineal care - infection, inadequate repair, wound breakdown/non healing
2. urinary retention
3. dyspareunia - painful/difficult sex
   4.headache
4. fatigue
   6.back ache
5. constipation
6. heamorrhoids
7. breast and nipples - redness, painful, cracked and mastitis

Question 183

What mental health problems may be experienced in the postnatal period?

Answer 183

• 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 - several episodes of mental illness that begin suddenly, mania, depression, confusion, hallucinations, delusions

Question 184

What was the main outcome of the Peel Committee Report (1970)?

Answer 184

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

Question 185

What are the risks associated with Caesarean section? (3 main risks)

Answer 185

• 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 briths

Question 186

What is the medical model of birth?

Answer 186

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

Question 187

What is the social model of birth?

Answer 187

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

Question 188

What are some of the cultural issues during pregnancy?

Answer 188

• unintended pregnancy - delay in seeking prenatal care and having a premature baby, high levels of stress and depression
• pregnancy may or may not fit with the mothers plans
• social disapproval out of wedlock and for teenagers

Question 189

What was the outcome of the Midwives’ Act (1902)?

Answer 189

• 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

Question 190

What are the benefits of institutionalised childbirth? (5 points)

Answer 190

1. standardisation of care
2. access to good facilities to support childbirth
3. availability of populations of childbearing women and infants for the purposes of midwifery and obstetric training
4. faster access to emergency care
5. acces of effective obstetric analgesia

Question 191

What ar the risks of institutionalised childbirth? (5 points)

Answer 191

1. medicalisation
2. depersonalisation of birth
3. lack of privacy
4. inflexibility of labour and birth practices
5. limitation of resources

Question 192

What is the role of doctors in welfare?

Answer 192

you must consider the safety and welfare of children and young people, wether or not you routinely seen 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

Question 193

What are the indicators of a successful breastfeed?

Answer 193

• baby - audible and visible swallowing, sustained rythmic suck, relaxed arms and head, moist mouth, regular soaked nappies
• mother - breast softening, no compression of nipples at end of feed, relaxed

Question 194

What problems may occur with breastfeeding?

Answer 194

• nipple pain
• engorgement
• mastitis
• inverted nipple
• ankyloglossia (tongue ties)
• sleepy baby

Question 195

What is ‘quality’ in relation to health care?

Answer 195

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

Question 196

Why is there a heavy emphasis on quality management in healthcare?

Answer 196

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

Question 197

Why is consumer protection necessary? (3 medical practice deficiencies)

Answer 197

1. medicine has weak evidence base
2. large variations in clinical practice - doctors do give different treatments to patients with similar needs and personal; characteristics
3. failure to measure success outcomes in healthcare

Question 198

What data are available to improve patient safety? (3 sources)

Answer 198

1. hospital episode statistics (HES) - details referring GP, procedures given, duration of stay and discharge/death, lack of basic national data in primary care
2. patient reported outcome measurements (PROMs) - before and after procedure QoL measurements slowly developing
3. reference cost data - cost data are poor

Question 199

What is the summary hospital level mortality indicator (SHMI)?

Answer 199

The ratio between the actual number of patients who die within 30 days of discharge compared with the number that would be expected to die on the basis of average

Question 200

What are the key consumer protection agencies? (3 main ones)

Answer 200

• 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 (formally monitor) - ensures financial obligations are met in terms of balancing income and expenditure
• national institute for health and clinical institute (NICE) - set standards for treatment

Question 201

Who enforces the NICE guidelines?

Answer 201

royal colleges, GMC, professional audit

Question 202

How can consumer protection be improved?

Answer 202

• appraisal by peers
• revalidation by GMC
• medical audit as a compulsory part of routine practice and annual job planning
• GP and consultant contracts - increasing transparity and comapratve performance ion relation to activity, cost and patient reported outcomes
• transparency and accountability

Question 203

What is clinical governance?

Answer 203

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

Question 204

What are the types of neglect? (4 types)

Answer 204

1. physical
2. educational
3. emotional
4. medical

Question 205

What are the signs of neglect? (7 examples)

Answer 205

1. malnutrition, begging, stealing or hoarding food
2. poor hygeine, matted hair, dirty skin, body odour
3. unattended physical or medical problems
4. frequent lateness or absence from school
5. inappropriate clothing, especially inadequate clothing in winter
6. frequent illness, infections or sores
7. being left unsupervised for long periods

Question 206

What are the 4 types of child abuse?

Answer 206

1. physical abuse - deliberate aggressive actions on the child that inflict pain
2. neglect - failing to provide a childs needs
3. psychological abuse - behaviour towards children which cause mental anguish or deficits
4. sexual abuse - when someone touches a child in a sexual way or commits a sexual act with him or her

Question 207

Who are the people involved in reproductive ethic debates? (3 main parties)

Answer 207

1. parents - procreative autonomy, parents wishes regarding procreative choice should be respected, state interference should be minimal
2. future or existing child - parents wishes should not be respected if not in interests of future or existing child
3. their parties including the state - use of resources, healthcare providers objections of conscience

Question 208

What was the main outcome of the human fertilisation and embryology act (1990)?

Answer 208

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)’

Question 209

What were some of the criticisms of the ‘welfare criterion’? (3 main criticisms)

Answer 209

• Fertile couples don’t have to meet this criterion
• predicting the welfare of future children is very difficult
• research suggests not the case that fatehr is always required for a child to flourish

Question 210

What was the main outcome of the human fertilisation and embryology act (2008)?

Answer 210

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

Question 211

What is the pro-life argument?

Answer 211

• abortion ends the life of a foetus
• human foetus has the moral status as a person
• it is wrong to end the life of a person or something with moral status therefore abortion/ termination. of pregnancy is morally wrong

Question 212

What is procreative autonomy?

Answer 212

• To have control over one’s reproductive capabilities
• the freedom to choose wether or not to have children

Question 213

What did the abortion act (1967, amended 1990) state?

Answer 213

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 mental or physical health
- continuing pregnancy would involve risk to the life of the pregnant woman
- risk that if the child was bron it would suffer from physical or mental abnormalities

Question 214

What are the arguments for assisted reproduction? (4 arguments)

Answer 214

1. procreative autonomy
2. helps get around fertility problems
3. more successive than other forms of assistive reproductive technology
4. can help single women and same sex couples have a child

Question 215

What are the arguments against assisted reproduction? (7 arguments)

Answer 215

1. involves destruction of embryos
2. higher risk of multiple pregnancy with associated risks of mortality and morbidity
3. is unnatural
4. encourages the mentality which views people as things which can be bought or sold as wanted
5. IVF babies are more at risk of birth defects than naturally conceived babies
6. psychological and physical health risk on parents
7. ART can be expensive

Question 216

What is pre-implantation genetic diagnosis and what are the associated ethical issues?

Answer 216

• 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’

Question 217

What provisions, if any, should be made for doctors who conscientiously object - what are the 3 views?

Answer 217

1. 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
2. objections should never be respected - womens interests should always take priority, sometimes argued that id doctors dont like this then they shouldnt have chosen medicine as a profession
3. objections can sometimes be respected (the GMC postion) - it might be possible for womens interest to be met whilst at same time not requiring doctors to do something that was cause them a great deal of distress e.g. can perhaps refer patients to abortion services, provide patients with information

Question 218

Which act says a 16 year old has full capacity?

Answer 218

The Family Law Reform Act of 1969

Question 219

What is Gillick competency?

Answer 219

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

Question 220

What are Fraser guidelines?

Answer 220

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

Question 221

What should you do before conducting an intimate examination? (5 steps)

Answer 221

1. explain to the patient why the examination is necessary and give the patient the oppourtunity to ask questions
2. explain what the examination will involve
3. get consent and record that the patient has given it
4. offer a chaperone
5. give the patient privacy to undress

Question 222

What is the role of the midwife in postnatal care? (7 key points)

Answer 222

• Screening/identification of actual and/or ‘at risk’ patients
• pregnancy and post natal period are window of oppourtunity to make lifestyle changes - smoking cessation, diet, exercise
• signposting - liasing and referal
• mental health services - MDT working
• health promotion - women and family
• source of information - bonding, breastfeeding
• reassurance and support
• safeguarding - vulnerable adult or child

Question 223

What are the aims from NICE postnatal care up to 9 weeks after birth guidelines (2006, updated 2015)?

Answer 223

• a documented individualised post natal care plan for everyone
• communication particulary about transferring care
• information given - empower women to take care of their own and babies own health
• assess the health and wellbeing of the woman and her baby
• alert women to signs and symptoms of potentially life-threatening conditions
• encourages breast feeding - large proportion of post natal care
• assess emotional wellbeing
• parents should be given information regarding assesing babies general condition, identifying common health problems, how to contact health care professional or emergency serviecs if needed

Question 224

Who is in the pregnancy MDT? (7 roles)

Answer 224

1. midwives
2. GPs
3. obstetrics
4. support workers
5. health visitors
6. maternity care assitants
7. public health practitioners

Question 225

What is the role of MDT postnatal care and support teams?

Answer 225

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

Question 226

What are some of the barriers to MDT work?

Answer 226

• seperate 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 work load
• lack of appropriately trained staff

Question 227

What is the importance of research-informed practice? (5 points)

Answer 227

1. personal experience is biased in various ways
2. research reports findings for more patients than we can hope to see in personal experience
3. research involves the application of scientific method - testing of hypothesis, systematic data collection, analysis designed to minimise bias
4. recommendations have been assessed for their clinical and cost effectiveness from NHS

Question 228

What is the research cycle?

Answer 228

1. Identify a clinical problem
2. basic research - labatory based
3. applied (clinical) research
4. clinical care

Question 229

What is the implementation gap?

Answer 229

Gap between scientific understanding and patient care

Question 230

What are the barriers to implementation of research-informed practice? (4 barriers)

Answer 230

1. characterisitics of recommendations - easy to follow, compatible with existing norms, need for new skills, complexity of recommendations
2. characteristics of the adopters - knowledge, attitudes, skills and abilities
3. characterisitics of the organisation - limitations and constraints, organisational culture
4. characteristics of the environment - social influence, influential peers

Question 231

What is quality improvement (QI)?

Answer 231

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

Question 232

What does quality improvement involve? (5 aspects)

Answer 232

1. engage participants across organisational levels
2. foster environment where improvement and innovation are viewed as normal
3. empowering staff to strive for change
4. provide knowledge and methods to implement change
5. remove barriers to change

Question 233

Give some examples of quality improvement initiatives

Answer 233

• revision of professional roles
• introduction of MDTs
• changing skill mix, or in the setting of service
• facillitate audit and benchmarking cycles to identify variations in practice and outcomes that may be targets for QI efforts
• network recognition for high quality service,
• promote interinstitutional communication and collaboration (and interinstitutional competition)

Question 234

What makes a quality improvement initiative effective? (3 aspects)

Answer 234

1. passive dissemination of information such as distribution of educational materials or didactic lectures, is generally ineffective in driving change
2. multifaceted intervention that act on different levels of barriers to change are more likely to achieve improvements in policy and practice
3. key - tailors to the key barriers no ‘just the usual’ approach

Question 235

What is quality and outcomes framework (QOF)?

Answer 235

annual reward and incentive program detailing GP practice achievement results
- enables commisioners to rewards excellence across key domains
- aims to improve standards of care by assessing and benchmarking quality of care patients recieve - compares delicery and quality of care against previous years

Question 236

Does quality and outcomes framework work?

Answer 236

improvements associated with finiancial incentives seem to be achieved at the expense of small detrimental effects on aspects of care that werent incentivised
- following the removal of incentives, level of performance across a range of clinicial activities generally remained stable

Question 237

What was the aims of national commission for quality and innovation (CQUINs) 2014-15?

Answer 237

• friends and family test - incentivise high performing providers
• improvement against the NHS safety thermometer - particularly pressure ulcers
• improving dementia and delerium care
• improving diagnosis in mental health

Question 238

What is the incidence of falls in the elderly?

Answer 238

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

Question 239

What are the possible consequences of falls?

Answer 239

• 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

Question 240

What are the risk factors for falls?

Answer 240

• muscle weakness
• history of falls
• gait deficits
• balance defecit
• visual deficit
• arthritis
• impaired ADL
• cognitive impairment
• age (>80 years)
• medical conditions - PD, stroke, hypotension, depression, epilepsy, dementia, arthritis, peripheral neuropathy, dizziness, vertigo

Question 241

How can falls be prevented/decrease risk?

Answer 241

• increase activity - diversity of PA
• weekly walk for exercise
• strong family networks
• multifactorial falls risk assessment
• multifactorial intervention
• education and information

Question 242

What doesn’t help reduce falls?

Answer 242

• brisk walking
• residential care setting - causes an increase
• HIIT - increases injury and strain
• educational and behavioural preventions alone - need further methods

Question 243

What is QALY?

Answer 243

Quality Adjusted Life Years
- 1 QALY = 1 year in perfect health
- e.g. if an illness reduces quality of life by 20% and this affects 10 people then 2 QALYs are lost

Question 244

What is the cost of falls for the NHS each year?

Answer 244

£1.3 billion

Question 245

What is the cost of hip fractures for the NHS each year?

Answer 245

• £12,000 per patient
• around £720million per year

Question 246

What is a common fracture in elderly people?

Answer 246

Fracture of the neck of femur

Question 247

What are the two types of fracture of the neck of femur?

Answer 247

• 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)

Question 248

What is avascular necrosis?

Answer 248

death of bone tissue due to lack of blood supply
- can lead to tiny breaks in the bone and the bones eventual collapse

Question 249

What is the main risk factor associated with increased risk of fracture?

Answer 249

Osteoporosis

Question 250

What are the risk factors for hip fractures? (10 examples)

Answer 250

1. low bone mineral density (BND) - is associated with incresed fracture risk
2. age - every 5 year increase doubles the risk
3. female gender
4. low body weight (correlates with bone density)
5. FHx of hip fracture
6. prior Hx of hip fracture
7. smoking
8. ethnicity - people of afrocaribbean descent have very low fracture risk
9. corticosteroid use
10. medication e.g. psychotropic drugs

Question 251

How can hip fractures be prevented?

Answer 251

• fall prevention
• bone protection - medication (bisphosphonates, calcium and vitamin D), hip protection

Question 252

What is primary prevention?

Answer 252

Avoidance of disease before any signs or symptoms develop

Question 253

What is secondary prevention?

Answer 253

Avoidance of progression or later problems, signs or symptoms present

Question 254

What would be primary and secondary prevention be in relation to stroke?

Answer 254

• primary - no history of stroke or TIA
• secondary - after either of these have occurred

Question 255

What is the prevention paradox?

Answer 255

• 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 much greater effect

Question 256

What are the effects of targeting population for prevention?

Answer 256

• larger potential benefit for community
• low potential benefit to individual
• may be low perceived benefit to individual

Question 257

What are the effects of targeting high risk groups for prevention?

Answer 257

• larger potential benefit to the individual
• smaller effect in population rate of stroke
• many of the conditions you treat are asymptomatic
• many of the the treatments have side effects

Question 258

Which group of people are at the highest risk from stroke?

Answer 258

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

Question 259

What medication is used for secondary prevention of strokes?

Answer 259

• ischaemic - clopidogrel, statins, anti-hypertensives, anticoagulant if AF
• haemorrhagic - anti-hypertensives

Question 260

What percentage of people who have strokes are under 50 years old?

Answer 260

<20%

Question 261

What is the incidence in strokes in men and women?

Answer 261

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

Question 262

What are the non-modifiable risk factors for stroke?

Answer 262

• age
• gender
• race - south asian decent with western lifestyle
• FHx - rare congenital (in young people (CADASIL)

Question 263

What are the modifiable risk factors for strokes? (6 factors)

Answer 263

• high BP
• diabetes
• AF
• smoking
• hyperlipidaemia
• obesity

Question 264

What did the PROGRESS trial show?

Answer 264

Reducing blood pressure after stroke reduces risk of stroke recurrence

Question 265

What are the barriers for initiating medical therapies for conditions with no obvious symptoms? (6 barriers)

Answer 265

• misinformed
• not caring
  -side effects for tablets
• forgetfullness
• depression
• cognitive impairments

Question 266

What is a confounding factor?

Answer 266

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

Question 267

How can we limit confounding factors and what are the effects? (4 strategies)

Answer 267

• 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 mathced on the possible confounder, make case and control group as similar as possible on the confounder and then ask about exposure staus; use for strong confounders like age and sex
• stratification - analyse exposure-outcome association in different subgroups of the confounder, recombine data and used a weighted average of the strata; limitations - to take into account all confounders would require lots of strata
• multiple variable regression - you can adjust for the effects of multiple confounders, try and produce a linear model between the outcome and different exposures; allow for adjustment of estimates fir confounding

Question 268

What is standardisation?

Answer 268

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

Question 269

What is standardised mortality ratio (SMR)?

Answer 269

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

Question 270

What is direct standardisation?

Answer 270

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

Question 271

What is indirect standardisation?

Answer 271

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

Question 272

Why do we have waiting lists?

Answer 272

• 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 infinite

Question 273

Why are waiting times important to patients? (5 examples)

Answer 273

• 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 extremly distressing in itself
• patients family life may be adversly affected by waiting
• excessive waiting times may be symptoms of inefficiencies in the healthcare systems and should be addressed as part of good management

Question 274

How can you measure waiting times? (3 methods)

Answer 274

• average waiting times (mean or median)
• proportion who waited longer than ‘x number of days’
• average wait of people currently on the list

Question 275

What are the theories of NHS waiting lists?

Answer 275

• the backlog - implies a need for occassional emergency injection of funds
• demand management - waiting acts as a ‘price’ to deter frivolous use
• allows NHS resources to be fully employed - dont want lots of spare capacity as this is a waste
• waiting lists are caused by underfunding and inefficiency

Question 276

How can the NHS reduce waiting times? (4 methods)

Answer 276

• 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 aprts of the local NHS work together to achieve waiting time improvements in the bets interest of patients

Question 277

What was the 2002-2008 policy ‘targets and terror’?

Answer 277

• performance management of Trust and PCTs based on achievement of target waiting times
• hospitals recieve an overall performance score and managers could loose jobs if targets missed

Question 278

What are the pros of ‘targets and terror’ policy?

Answer 278

• 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

Question 279

What were the cons of ‘targets and terror’ policy?

Answer 279

• sacrifice of proffessional autonomy - managers pressuring doctors, may be forced to treat less urgent due to waiting times
• unmeasured performance sufferers - things that dont 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 till they are throough the doors so essentially cheating
• data manipulation and fraud

Question 280

What is possible criteria for priority on a waiting list? (6 examples)

Answer 280

• clincial urgency
• clinical severity
• potential health gain - productivity and economic loss
• equity waiting e.,g. poverty
• length of time waiting

Question 281

What are the social consequences of deafness?

Answer 281

• social impact - difficult to have conversations, isolation, intimacy issues, problems at work
• psychological impact - anger, low confidence, frustration, depression, embarrassment
• praticual issues - doorbells, phones, theaters or cinemas, tv, alarms

Question 282

How can a stroke affect communication?

Answer 282

• aphasia (and sometimes dysphagia) - difficulty in the genration of speech and sometimes its comprehension
• dysarthria - difficulty or unclear articualtion of speech that is otherwise linguistically normal (due to muscle weakness)
• dyspraxia - affect movement and coordination, cannot move muscles in the correct order and sequence to make the sound needed for clear speech

Question 283

What are the social consequences of speech and communication difficulties?

Answer 283

• 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 - communication may require a lot of effort

Question 284

What areas can medico-legal implications occur in a person with epilepsy?

Answer 284

• determination of fitness to drive and other simarly dangerous activities
• determination of intent for alleged criminal actions

Question 285

What are the rules for whether people can drive with epilepsy?

Answer 285

• 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 veichles such as lorries, heavy good veichles and other specialised types of veichles - unlikely to qualify for group 2 license, need to be seizure free for 10 years and have not taken epilepsy medication for 10 yrs

new rules relating to wether people can dirve if:
- thhyhe have only had seizures while in their sleep
- they have only had a seizure that do not affect their consciousness
- theri dr changes their dosage or medication but theyve now gone back to the original dosage or medication

Question 286

What are CAMs?

Answer 286

• complementary - non-mainstream practice is used together with convenient medicines
• alternatives - non mainstream practce is used instead of conventional medicines

Question 287

What are the 5 big CAMs?

Answer 287

• accupuncture
  chiropractic
  herbal medicine
  homeopathy
  osteopathy

Question 288

What is the underlying principle with CAMs?

Answer 288

• self healing is triggered
• long term effects may be due to physioogical (re-)learning and behavioural/lifestyle changes integral to treatments
• each therapy has its own mechanism - most poorly understoof

Question 289

What percentage of CAMs are covered by the NHS?

Answer 289

10%

Question 290

What are the barrier to CAMs on the NHS? (5 main barriers)

Answer 290

• regulatory issues
• financial concerns in the NHS
• tribalism - different medical specialities ‘hold on’ to their patch
• inertia - resistance to change
• mixed evidence of effectiveness - not all are properly evidence based

Question 291

Why should CAMs be provided by the NHS? (5 arguments)

Answer 291

• patient choice
• preventative healthcare agenda
• commisioning changes
• personal budgets
• growing evidence base

Question 292

Which complementary therapy is most used for MSK problems?

Answer 292

Osteopathy

Question 293

What is osteopathy used mainly to treat? (5 problems)

Answer 293

• back pain
• repetitive strain injury
• changes in posture in pregnancy
• postural problems caused by driving or work strain
• the pain of arthritis and sports injuries

Question 294

What do chiropractors mainly treat?

Answer 294

• back, neck and shoulder problems
• joint, posture and muscle problems
• leg pain and sciatica
• sports injuries

Question 295

What is acupuncture used to treat?

Answer 295

• MSK patients
• fertility/pregnancy - has become much more popular
• neurological pain
• depression
• eczema
• chronic pain
• irritable bowel

Question 296

Why are people using acupuncture?

Answer 296

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

Question 297

What is the evidence base for acupuncture?

Answer 297

• accupuncture correklated with physiological parameters i.e with decreases in brain flow
• can be seenas having overall effect vs usual care
  more effective than no treatment of sham treatment for low back pain (indicate more than a placebo) but there are no differences in effectiveness compared to other convential therapies
• accupuncture, osteopath chiropractic shoen to be effective when compared to usual care
• more and better research needed

Question 298

What are the criticisms of acupuncture?

Answer 298

• is the effect too small and not clinically relevant
• NSAIDS are commonly given for chronic back pain - NSAIDs vs placebo and accupuncture vs placebo have simialr effect for pain reduction

Question 299

What does the NICE guidelines state about acupuncture in lower back pain, osteoarthritis, and headaches?

Answer 299

• lower back pain - consider manual therapy, dont offer acupuncture
• osteoathritis - manipualtion and stretching should be considered as an adjunct to core treatments, dont offer acupuncture
• headache/migrane - consider course of up to 10 sessions of acupuncture over 5-8 weeks

Question 300

What are the 5 categories for significant impaired decision making ability?

Answer 300

• lack of insight - person suffers from some disability but seem unaware of the existence of their disabliltiy
• cognitive impariment - e.g. dementia
• presence of psychosis
• severe depression symptoms
• learning disability

Question 301

Why is it important to support patients decision making? (5 reasons)

Answer 301

• patients generally happier if they can make their own decisions
• enables patients to have self determination, autonomy
• likely to facilitate other positive goods - DR- pt relationship
• professional requirement (GMC)
• legal requirement - mental capacity act 2005

Question 302

How might doctors assist patients in making decisions? (4 methods)

Answer 302

• using a different form of communiaction
• providing information in a more accessible form
• treating a medical condition affecting the persons capacity
• having a structured programme to improve persons capacity

Question 303

Which act are capacity determinants governed by?

Answer 303

Mental capacity act (2005)

Question 304

According to the mental capacity act, when does a person lack capacity?

Answer 304

A person lacks capacity if they are unable to:

Question 305

What are the 5 key principles of the mental capacity act?

Answer 305

1. 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
2. right to be supported to make own decisions - use different forms of communication, provide information in different formats, treat condition that is impacting and thus restore capacity
3. right to make eccentiric and unwise decisions - a person is not to be treated as unable to make a decision merely because it is an unwise one
4. best intrests - a decision made under the MCA for soemone lacking capacity must be done in their best interests
   5, least reastrictive dscision - before the decision is made you should explore other less restrictive options

Question 306

How many people in the UK have dementia?

Answer 306

Approximately 850,000 people

Question 307

How might dementia first present?

Answer 307

NAME?

Question 308

What is the impact of diagnosis of dementia on a patient?

Answer 308

NAME?

Question 309

What determines the response of the patient to the diagnosis of dementia?

Answer 309

NAME?

Question 310

What is the impact of diagnosis on the carers?

Answer 310

NAME?

Question 311

What determines the response of the carer to the diagnosis?

Answer 311

NAME?

Question 312

What are the benefits of diagnosis?

Answer 312

NAME?

Question 313

Describe the effect of dementia on the patient, spouse/partner, children and carers

Answer 313

NAME?

Question 314

How much of the cost of dementia is paid by people with dementia and their families?

Answer 314

2/3 = £17.4 billion

Question 315

What percentage of carers don’t receive enough support?

Answer 315

43%

Question 316

Why are people with dementia at high risk of elder abuse? (3 main reasons)

Answer 316

NAME?

Question 317

What are examples of advanced care planning?

Answer 317

NAME?

Question 318

What are advanced directives?

Answer 318

• Extends patient autonomy to apply in situations where they don’t have capacity as defined under the MCA 2005

Question 319

What are advanced directives valid and applicable?

Answer 319

• Patient is 18+ - note MCA is for 16+ but only 18+ can refuse treatment

Question 320

What is Ulysses arrangement?

Answer 320

Advanced directive for bipolar disorder

Question 321

What are the pros of advanced directives?

Answer 321

NAME?

Question 322

What are the cons of advanced directives?

Answer 322

• Difficulty to verify if the patient’s opinion has changed since making AD
• difficult to ascertain wether the current circumstances are what the patient foresaw when making the AD
• posibility of coercion
• possible wrong diagnosis
• can patients imagine future situations sufficiently and vividly enough to make their current decisions accurately informed.

Question 323

What are some of the research atrocities in history?

Answer 323

• nazi medical experiments (Nuremberg trials)
• Willowbrook study - injected vulnerable children with Hep B to produce vaccines
• Tuskegee syphyilis study - African american men given syphilis but not antibodies, to see disease progression
• Alder Hey - retaining children organs without consent
• Wakefield - MMR scandal

Question 324

What is the Nuremberg Code (1947)?

Answer 324

The Nuremberg code resulted from the Nuremberg trials. It was an early code for research ethics principles, including:

Question 325

What is the Helsinki declaration (1964)?

Answer 325

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

Question 326

What are some research ethics principles? (6 examples)

Answer 326

• Usefulness - valid, good method, hasn’t been done before, strong justification

Question 327

What is valid consent?

Answer 327

Voluntary, informed, patient is competent

Question 328

What does voluntary consent mean?

Answer 328

NAME?

Question 329

What should patients be given to facilitate consent?

Answer 329

NAME?

Question 330

What is confidentiality and why it is important?

Answer 330

NAME?

Question 331

How can we increase the level of confidentiality?

Answer 331

NAME?

Question 332

What is an ethics committee?

Answer 332

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

Question 333

Why do we need ethics approval? (5 reasons)

Answer 333

NAME?

Question 334

When is ethics approval needed? (3 examples)

Answer 334

NAME?

Question 335

What are some of the types of research ethics committees?

Answer 335

NAME?

Question 336

What does the human tissue act (2004) state about research?

Answer 336

• 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 functioning of the human body
• consent is not required if the use of tissue obtained from living patient if the tissue is anonymous to the researcher and project has ethics approval

Question 337

What percentage of deaths does CHD cause in the UK?

Answer 337

• 29% men
• 28% women

Question 338

Why are the death rates falling from CHD?

Answer 338

NAME?

Question 339

What is the effect of health inequalities on CHD?

Answer 339

Lower social class at higher risk - health behaviours

Question 340

What are the modifiable risk factors for CHD?

Answer 340

• elevated blood cholesterol
• high LDL, low HDL
• high BP
• diabetes
• smoking
• obesity
• excessive alcohol
• inactivity
• excessive stress

Question 341

What is risk?

Answer 341

The probability of an event in a given time period

Question 342

What is the equation for risk ratio?

Answer 342

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

Question 343

What is the equation for risk difference?

Answer 343

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

Question 344

What is odds ratio?

Answer 344

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

Question 345

What is the equation for odds ratio?

Answer 345

OR = ad/bc

Question 346

What is population attributable risk?

Answer 346

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

Question 347

What is the leading cause for cancer mortality?

Answer 347

Lung cancer

Question 348

What are the main risk factors associated with lung cancer?

Answer 348

NAME?

Question 349

What percentage of lung cancer cases are cause by smoking?

Answer 349

90%

Question 350

What is the second leading cause of lung cancer after smoking?

Answer 350

Radon

Question 351

What are the different types of lung cancer?

Answer 351

• Small cell (13%)
• non small cell (87%) - Adenocarcinoma (>40%), squamous cell carcinoma (20%), mesothelioma (2%)

Question 352

How many people in the world are infected with TB?

Answer 352

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

Question 353

How many deaths per year does TB cause (million)?

Answer 353

1.5 million people (in 2020 according to WHO)

Question 354

What are the factors associated with recent increases in the prevalence of TB? (4 main factors)

Answer 354

NAME?

Question 355

What time of year does TB incidence peak?

Answer 355

Spring/summer

Question 356

What can be done to address rising rates of TB?

Answer 356

NAME?

Question 357

What is the prevention paradox?

Answer 357

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

Question 358

What are the pros of ‘high risk’ approaches to health promotion?

Answer 358

NAME?

Question 359

What are the cons of ‘high risk’ approaches to health promotion?

Answer 359

• screening is difficult
• palliative and temporary
• limited potential due to lack of people
• labelling

Question 360

What are the pros of ‘population’ approaches to health promotion?

Answer 360

Large potential as targeting many people

Question 361

What are the cons of ‘population’ approaches to health promotion?

Answer 361

NAME?

Question 362

What are some examples of occupational lung disease?

Answer 362

NAME?

Question 363

How have occupational health risks changed over time?

Answer 363

• Better environmental control an health and safety - e.g. from mid 20th century with coal mining, etc.

Question 364

What is occupational asthma?

Answer 364

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

Question 365

Give some examples of occupations that are at a higher risk for occupational asthma

Answer 365

NAME?

Question 366

What history would you expect from a patient with occupational asthma?

Answer 366

NAME?

Question 367

Give some occupational causes of COPD

Answer 367

NAME?

Question 368

What is pneumoconiosis?

Answer 368

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

Question 369

What is simple coal workers pneumoconiosis?

Answer 369

• 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

Question 370

What are possible complications with coal workers pneumoconiosis?

Answer 370

NAME?

Question 371

What is silicosis?

Answer 371

NAME?

Question 372

What is siderosis?

Answer 372

NAME?

Question 373

What is acute pneumonitis?

Answer 373

• acute inhalation of a substance that causes symptoms immediately
• can be casued by chlorine, ammonia, organic chemicals, metallic compounds
• form of acute respiratory distress syndrome

Question 374

What is hypersensitive pneumonitis?

Answer 374

• Type 3 hypersensitivity reaction (immune complex deposition)
• inflammation of the alveoli within the lung caused by hyperesentivity to inhaled organic dust

Question 375

What are some causes of hypersensitive pneumonitis?

Answer 375

• Bird fancier’s lung - due to feathers and bird droppings

Question 376

What percentage of lung cancers in men are related to occupation?

Answer 376

10%

Question 377

What is asbestos?

Answer 377

• a naturally occuring silicate
• used lots in 1950-60s as a building material - fire retardant and used in cement
• in 1960s was found to cause malignant mesothelioma (pleural tumour)
• only as small amount needed to cause it

Question 378

What are the 2 types of asbestos fibres?

Answer 378

• serpentines - while curly asbestos, relatively harmless, cleared with mucocillary escelator
• amphiboles - short, sharp, brown/blue asbestos - have malignant potential

Question 379

What is mesothelioma?

Answer 379

• cancer of the mesothelium almost inevitably caused by occupational exposure to asbestos
• latency period around 40 years

Question 380

Where are claims submitted for compensation for occupational illness in the UK?

Answer 380

Disability benefits centre of benefits agency (DSS)

Question 381

What is decision analysis?

Answer 381

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

Question 382

What does decision analysis assume?

Answer 382

• decision process is rational and logical
• rational decision maker will choose option to maximise utility

Question 383

What are the stages ind decision analysis? (4-5 stages)

Answer 383

1. Structure the problem as a decision tree - identifying choice, information (what is and is not known) and preferences
2. assess the probability of every choice branch
3. assess the utility of every outcome
4. identify the option that maximises unexpected utility
5. conduct sensitive analysis to explore effect of varying judgments

Question 384

What do squares and circles mean on decision trees?

Answer 384

> squares - indicated decision, choice between actions

> circles - indicated chance (probablity), represents uncertainty, potential outcomes of each decision

Question 385

How do you calculate expected utility?

Answer 385

Expected utility = utility value x probability

Question 386

What is sensitive analysis?

Answer 386

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

Question 387

What are preference sensitive and probability sensitive decisions?

Answer 387

> preference sensitive - the person might feel strongly about the side effects of the treatment

> probability sensitive - sensitive to the changes in the chance of different outcomes

Question 388

What are the benefits of using decision analysis to make decisions? (5 benefits)

Answer 388

• makes all assumptions of decision explicit
• allows examination of the process of making the decision
• integrates research evidence into decision process
• insight grained during the process may be more important than the generated numbers
• can be used for individual decisions, populations and cost-effective analysis

Question 389

What are the negatives of using decision analysis to make decisions?

Answer 389

• 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 state of health they have not experienced, different techniques will result in different numbers, subject to presentation framing effects, approach is reductionist

Question 390

What is the ICF model of disability?

Answer 390

Functioning and disability are multi-dimensional concepts relating to:

Question 391

What is palliative care?

Answer 391

• active hollistic care of patients with advanced progrssive disease
• aims to treat or manage pain and other ohysical symptoms and will also help with and psychological, social or spiritual needs

Question 392

What are the goals of palliative care? (8 goals)

Answer 392

• improve QoL
• 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 persons illness and in the bereavement process
• uses an MDT approach to adress the needs of the person who is ill and their families

Question 393

Who is general palliative care given to?

Answer 393

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

Question 394

Who is specialised palliative care for?

Answer 394

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

Question 395

Who provides specialised palliative care?

Answer 395

> NHS - community/hospital clinic nurse specialist, some consultants, some inpatient units, macmillan

> voluntary - hospice services, inpatient beds, independent charities, macmillan

Question 396

What is end of life care?

Answer 396

branch of palliative care - care for people reaching the end of their life
- ‘end of life care pathway’ - last 48 hours of life

Question 397

What are some of the challenges for the future of palliative care?

Answer 397

• inequality of service provision and standards
• funding
• training, recruitment, retention
• maintaining sense of humanity and compassion - increasing technologies and treatment for managing diseases

Question 398

What is ‘total pain’?

Answer 398

Recognises pain as being physical, psychological, social and spiritual

Question 399

What are the different types of nurses involved in palliative care? (4 main types)

Answer 399

• District nurse - primary health care team, community based, generic palliative care skills, ‘hands on’ nursing skills
• practice nurse - primary care health team, practice based, generic palliative care skills, ‘hands on’
• marie curie nurses - community based, arranged by district nurse, specialist palliative care skills, ‘hands on’
• macmillan nurses - community or hospital based, specialist palliative care advice, support, resource

Question 400

Where is the preferred place of death?

Answer 400

• most people wish to die at home
• few people wish to die at hospital
• most people die in hospital
• hard to plan because you dont know when it will happen

Question 401

What percentage of admission notes document the CPR decisions?

Answer 401

10%

Question 402

What percentage of in-hospital CPR is not appropriate?

Answer 402

40-50%

Question 403

What is DNACPR?

Answer 403

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

Question 404

What are Bowlby’s 4 stages of grief?

Answer 404

• numbness
• yearning/ pining and anger
• disorganisation and despair
• reorganisation

Question 405

What are the symptoms of grief?

Answer 405

> anger, anxiety, fatigue, guilt, helplessness, lonliness, sadness, shock, numbness, yearning
somatic sensations - stomach, chest, throat, sensitivity to noise, breathlessness, muscle weakness, lack of energy, dry mouth
concentration impairment - preoccupation with deceased, hallucinations, disbelief
sleep and appetite disturbances, absent midnessess, social withdrawal,dreams of deceased, avoidance of reminders, searching and calling out, shighing =, overactivity, crying

Question 406

What is Warden’s tasks of mourning? (4 tasks)

Answer 406

1. Accepting the reality of the loss e.g. come to terms with the person being ‘gone’
2. work through the pain of the grief
3. adjust to an environment in which deceased is missing
4. emotionally relocate the deceased and move on with life

Question 407

What factors affect the severity of grief? (6 factors)

Answer 407

• closeness of the relationship
• meaningfulness of the relationship
• nature of the relationship prior to death
• expectedness and manner of the death
• age and developmental status
• social support

Question 408

What is spirituality?

Answer 408

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

Question 409

How can religious beliefs impact on bereavement?

Answer 409

> belief in the afterlife - the continuing existence of loved one and possibility of meeting again
continued attachment - prayer as a mean of communication
defence against beliefs about personal death
religous funeral rituals aid and progress grief process
religious funeral rituals recruit social support

Question 410

What is pathological grief?

Answer 410

• 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 a dead persons room)
• major depressive disorders >2 months after loss

Question 411

What is the myth of the neutral therapist?

Answer 411

• Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
• this will coming across in their questioning/ direction of questioning

Question 412

What are CDSS?

Answer 412

Clinical decision support system - designed to aid clinician decision making

Question 413

What are the different types of CDSS?

Answer 413

• computerised
• paper based
• reminder systems
• develop to aid with particular decisions

Question 414

What are some examples of CDSS? (4 examples)

Answer 414

> reminder systems - screening, vaccination, testing, medication use
decision systems - model individual patient data against epidemiological data
prescribing - advice on drug dosage, highlights potential drug interaction
condition management - assists monitoring patients

Question 415

What are the effects of computer support on prescribing? (6 main effects)

Answer 415

1. reduce time to reach theraputic stabilisation
2. reduce risk of toxic drug level
3. reduce length of hospital stay
4. increase size of initial dose
5. increased serum drug conc.
6. no change in adverse effect of drug

Question 416

Do CDSS work?

Answer 416

• can improve practitioner performance in diagnosis, disease management, prescribing/drug dosing, rates of vaccination, screening
• evidence for effects on patient outcomes not so robust

Question 417

What are patient decision aids?

Answer 417

• support patient in decision making
• help patients understand probable outcomes of options
• help patient consider the personal value they place on benefits v harms
• include additional information - disease, costs, probablility of outcomes, peoples opinions

Question 418

What is the key issue with patient decisions aids?

Answer 418

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

Question 419

What improves practice when using decision support? (4 examples)

Answer 419

1. providing decisions as part of the clinical workflow
2. providing recommendations for management (not just patient assessments)
3. providing decision support when and where decision making was happening
4. computer based decision support

Question 420

What are potential barriers to using CDSS? (4 examples)

Answer 420

• earlier negative experience of IT
• potential harm to doctor-patient relationship
• obscured responsibilities (loss of autonomy and reasoning)
• reminders increase workload

Question 421

What are potential facilitators of CDSS?

Answer 421

• self-control of CDSS
• if clinician can notice help in practice

Question 422

What is food poisoning?

Answer 422

Diarrhoea and vomiting with or without pain

Question 423

What are the major causes of food poisoning?

Answer 423

• not cooking food thoroughly (particularly meat)
• not correctly storing food that needs to be chilled
• keeping cooked food unrefrigerated for long periods of time
• eating foods that has been touched by someone who is ill or has been in contact with someone with diarrhoea or vomiting
• cross contamination

Question 424

What are some microbial infections that cause food poisoning?

Answer 424

> bacteria - salmonella, campylobacter, shigella, C. difficile
viral - norovirus, rotavirus
fungal - aspergilus
protozoal - cyrptosporidia, giardia

Question 425

What are some toxins that cause food poisoning?

Answer 425

> bacterial toxins - clostridium perfringens, s. aureus, clostridium botulinum
marine biotoxins - scombroid poisoning, shellfish, ciguatera

Question 426

What are some chemicals that cause food poisoning?

Answer 426

• heavy metals
• pesticides
• herbicides

Question 427

What is the most common cause of food poisoning?

Answer 427

Campylobacter

Question 428

Describe the clinical picture of salmonella infection (transmission, incubation, symptoms)

Answer 428

> transmission - ingestion of contaminated foods, faecal contaminations, person-person, infected animals
can cause enteric fever or enterocolitis
incubation period is 12-72 hrs
symptoms - vomiting, diarrhoea, fever, headache chills

Question 429

Describe the clinical picture of staphylococcus aureus infection (transmission, incubation, symptoms)

Answer 429

> transmission - contaminated foods by skin/nasal flora
produces enterotoxins
incubation of 24 hrs
symptoms - rapid onset, projectile vomiting and diarrhoea

Question 430

Describe the clinical picture of cryptosporidium infection (transmission, incubation, symptoms)

Answer 430

> 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

Question 431

Describe the clinical pictures of escherichia coli infection (transmission, incubation, symptoms)

Answer 431

> transmission - contaminated food, person-person
incubation - 1-6 days
symptoms - haemorrhagic colitis, 5% get haemolytic uraemic syndrome

Question 432

Describe the clinical picture of norovirus infection (transmission, incubation, symptoms)

Answer 432

> transmission - faecal-oral route, environmental contamination, contaminated foods/water
incubation-24/48hrs
symptoms - nausea, projectile vomiting, low-grade fever, diarrhoea

Question 433

Describe the clinical picture of clostridium perfringens infection (transmission, incubation, symptoms)

Answer 433

> transmission - contaminated cooked meats and poultry
incubation - 8-22hrs
symptoms - diarrhoea, abdo pain

Question 434

Describe the clinical picture of campylobacter infection (transmission, incubation, symptoms)

Answer 434

> transmission - raw/undercooked meats, unpasteurised milk, bird-pecked milk, untreated water, domestic pets with diarrhoea, persom-person
incubation - 2-5 days
symptoms - fever, headache, malaise, nausea, diarrhoea, vomiting is uncommon

Question 435

How can food poisoning be prevented?

Answer 435

> isolation
hand hygiene
protection
environmental cleaning
respiratory hygiene and cough etiquette

Question 436

What is ‘safe food’?

Answer 436

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

Question 437

What are concerns with food?

Answer 437

• food bourne illnesses
• nutritional adequacy
• environmental contaminants
• pesticides
• naturally occuring contaminants
• food additives

Question 438

What does the public health act state about food poisoning?

Answer 438

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

Question 439

What are some of the offences under the food safety act (1990)? (3 examples)

Answer 439

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

Question 440

What is hazard analysis critical control point?

Answer 440

• 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
• decide which of the identified points are critical to food safety
• 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 changes occur to the operation

Question 441

What are the objectives in food poisoning outbreaks? (3 objectives)

Answer 441

• reduce the number of primary and secondary cases
• reduce the harm consequent on the episode
• prevent further outbreaks

Question 442

What are the investigations done in food poisoning outbreaks?

Answer 442

• preliminary phase - is there an outbreak? confiming the diagnosis, what is nature and extent of outbreak?
• immediate steps - who is ill? how many cases? case finding; whats cause? is proper care being arranged? WHAT IMMEDIATE ACTION CAN BE TAKEN?

Question 443

What are outbreak outliers?

Answer 443

• OUTLIERS ARE CASES AT THE VERY BEGINNING OR END THAT MAY NOT APPEAR TO BE RELATED
• FIRST CHECK TO MAKE CERTAIN THAT THEY ARENT DUE TO DODING OR DATA ENTRY ERROR

Question 444

What might outbreak outliers represent? (6 examples)

Answer 444

• Baseline level of illness
• outbreak source
• a case exposed earlier than others
• unrelated case
• a case exposed later than the others
• a case with longer incubation period

Question 445

How can analytical epidemiological studies be useful to identify probable food source of outbreak?

Answer 445

• Compare food history of ill and well persons
• point source of outbreak - cohort study
• common source of outbreak - case-control study

Question 446

Which GI cancers are prevalent in which populations?

Answer 446

• oesophageal - middle east and china
• gastric - russia
• colon - western countries - usa, uk

Question 447

What dietary intake increase the risk of colorectal cancer?

Answer 447

Fat intake

Question 448

What is the evidence base for ‘5-a-day’?

Answer 448

• 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 5aday has imapct on cancer]

Question 449

Describe the relationship between beta carotene and cancer

Answer 449

• beta carotene in fruit/vegetables
• cohort studies inigcate protective relationship against cancer
• RCTs showed beta carotene increased risk of cancer
• cohort studies have reduced risk due to confounding factors - increased exercise, reduced smoking

Question 450

What are the problems with measuring diet?

Answer 450

• 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 likley to have similar environments and hence diets, so you arent able to apply the results to the population
• bias
• confounding

Question 451

What are the different measures of diet?

Answer 451

• food disappearance data
• household survey - what do u buy and who eats what?
• individual survey - 24 hour recall, food frequency (very open to bias), diet diary, biomarkers

Question 452

What are the pros and cons of food frequency qeustionnaires?

Answer 452

• pros - captures usual diet and less work to code/complete
• cons - don’t record actual diet as eaten, overestimates fruit and veg, poor measure of energy intake, less flexible

Question 453

What are the pros and cons of diet diaries?

Answer 453

• pros - record diet as eaten, better estimate of energy and absolute intake, more flexible
• cons - required effort to complete and expensive to code

Question 454

What are the main dietary associations with cancer? (7 examples)

Answer 454

• oesophageal - alcohol, obesity
• stomach - possibly salted preserved foods
• pancreas - overweight, obesity
• hepatic - aflatoxin contamination
• colorectal - preserved red meat, alcohol, body fat
• breast - alcohol, overweight
• urological - high calcium

Question 455

What is the trend of alcohol consumption in the UK?

Answer 455

• per capita consumption in the UK is lower than many european countries
• however tend to start earlier and drink more on single occasions (binge drinking)
• peak consumption was 2008 - related to affordability

Question 456

What percentage of men and women have an alcohol use disorder?

Answer 456

• 38% of men and 16% of women (16-64) have an alcohol use disorder (approximately 8 million people)

Question 457

Where is identification and brief advice (IBA) delivered?

Answer 457

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

Question 458

What specialised treatment is available for alcohol problems? (4 examples)

Answer 458

• CBT - common
• behavioural approaches - behavioural couples therapy, behavioural self- control for moderation goal
• motivational interviewing
• social behaviour and netweork therapy (SBNT)

Question 459

Which medical conditions are wholly attributable to alcohol?

Answer 459

• alcoholic liver disease
• alcoholic neuropathy
• chronic pancreatitis
• alcoholic cardiomyopathy
• alcoholic gastritis
• alcohol related accidents
• risk factors for -colon cancer, mouth and oesophageal cancer

Question 460

What are some of the social consequences of alcohol consumption?

Answer 460

• Death - declining since 2008
• crime and disorder
• domestic violence - involved in 73% of cases
• poor productivity at work
• absence/sick leave fro work
• family effects - 5 million families have to deal with problem drinker, arguments, violence, debt, relationship problems

Question 461

What are effective, moderately effective and less effective policies for alcohol related health promotion?

Answer 461

More effective policies:
- price increases - taxation, minimum price
- restricting availability - opening times, reduced outlet density, age restrictions

moderately effective policies:
- restricting exposure of young people to adverts
- treatment - identification and brief advise

less effective:
- drug and alcohol education
- mass media campaigns

Question 462

What are the key UK departments involved in alcohol policy? (2 main departments)

Answer 462

• home office - focus on public disorder
• department of health - focus on PH

Question 463

What was the ‘alcohol strategy (2021)’?

Answer 463

• minimum unit price policy dropped, multi-buy promotional offered werent banned as suggested
• local health bodies able to instigate review of licencses
• double fine for selling alcohol to underage people
• ‘enforced sobreity’ - 1 yr pilots based on us models
• overall alcohol consumption guidelines for adults
• alcohol included in the NHS check for adults 40-75

Question 464

What is efficiency?

Answer 464

• target regulation to those activities that give the greatest health gain for the money spent as this will maximise population health gain
• informing these choices requires estimation of value of what is given up when a patient is treated (oppourtunity cost) and the value of what is gained in terms of improvements to health of patients

Question 465

What is allocative efficiency?

Answer 465

Investing in healthcare are interventions that are worthwhile

Question 466

What is technical efficiency?

Answer 466

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

Question 467

What is equity in financing?

Answer 467

• geographical allocation of funding by weighted capitation
• resourcing determined by population weighted by need

Question 468

What is the class equality/inequality in health care?

Answer 468

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

Question 469

What is the concept of the ‘margin’?

Answer 469

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

Question 470

Why is the margin important?

Answer 470

• incremental investments in an activity may be associated with diminishing returns
  i.e. successive increase in activity yield declining benefits to the patient, the more you do less they beneift

Question 471

Why do we need economic evaluation?

Answer 471

• values both inputs (oppourtunity cost) and outputs (health outcomes) of any intervention
• assess if changes in resource allocation are efficient
• important because increasing healthcare expenditure needs best outcome for money

Question 472

How do you measure cost?

Answer 472

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

Question 473

How do you measure benefit?

Answer 473

Health gain = increase in length + QoL

Question 474

What is cost-minimisation analysis?

Answer 474

Chooses cheapest option between treatments that have identical outcomes

Question 475

What is cost-effective analysis?

Answer 475

• costs and outcomes are combined into a single measure e.g. reduction in BP
• allows comparison between treatments in the same therapeutic area only

Question 476

What is cost-utility analysis?

Answer 476

• combines multiple outcomes into a single measure (QALY) using QoL instruments e.g. EQ5D
• Allows comparison between alternatives with different theraputic categories

Question 477

What is cost-benefit analysis?

Answer 477

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

Question 478

When can cost-effectiveness analysis be used?

Answer 478

• if the outcome measures are just clinical
• if other more generic outcome measure used, use cost analysis to determine QALY

Question 479

What are the levels of resource allocation decisions?

Answer 479

• macro (societal) level - regarding health funding vs education or funding of certain drugs
• micro (clinical) funding - individual decisions regarding care of individual patients

Question 480

What are the arguments for and against age-based rationing being applied to macro-level resource allocation decisions?

Answer 480

• 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 disease could also cost the same amount

Question 481

Describe the Fair-innings argument (1997)

Answer 481

• older people have had a long life already, therefore fairer to divert resources to younger people
• elderly also have disproportionate share of the available resources allocated to them

Question 482

What are the contraindications to the Fair-innings argument?

Answer 482

• treating on the basis of need might mean older people don’t receive lower priority
• years of life saved shouldn’t matter, the quality of life is more importants (QALYs)
• fairness isnt the only thing that matters

Question 483

What are the arguments for and against age-based rationing being applied to micro-level resource allocation decisions?

Answer 483

• 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 risk of complications
• against - age alone isnt a good predictor of prognosis/complications, hence need case-by-case decisions, decisions based on age may be hidden form of discrimination

Question 484

What is age discrimination?

Answer 484

Unjustifiable difference in treatment based solely on age

Question 485

What is the difference between direct and indirect age discrimination?

Answer 485

• direct - direct differences in treatment based on age, cannot be justified
• indirect - neutral provision or practice that has harmful repurcussions on person based on age

Question 486

What is the GMC and laws view on age discrimination?

Answer 486

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

Question 487

How do calculate QALY?

Answer 487

• 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

Question 488

What leads to utilitarian justification?

Answer 488

QALYs focus on overall likely outcomes of resource allocations

Question 489

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

Answer 489

low - high priority, efficient HC
high - low priority

Question 490

What are the arguments for QALY-based assessments?

Answer 490

• maximises healthcare based on quality and quantity of life
• consider individual patient level when informing decisions about wether or not to proceed with an invasive procedure based on QALYs they are liekly to gain

Question 491

What are the arguments against QALY-based assessments?

Answer 491

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

Question 492

What is relationship between age and QALY?

Answer 492

• the older you are the fewer QALYs you will gain due to lower life expectancy + comorbidities
• doesn’t aim for ageism but is still discriminatory (indirect)

Question 493

What body appraises medical technologies in pounds per QALY?

Answer 493

NICE

Question 494

What is PICO?

Answer 494

Population
Intervention
Comparison
Outcome

Question 495

What are the 3 discrete steps in critical appraisal?

Answer 495

• are the results of the study valid?
• what are the results?
• can I apply ther results to this patients care?

Question 496

What is study validity and what should you look for?

Answer 496

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 sytematic fashion to lead to a false conclusion

Question 497

What are the different types of results?

Answer 497

• therapy - look at relative risk reduction, absolute risk reduction, odds ratio, number needed to treat, confidence intervals
• diagnosis - sensitivity, specificity, positive predictive value, negative predictive value, likelyhood ratio
• 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

Question 498

How should you apply the results of a critical appraisal?

Answer 498

• how similar are the patients of the study to your patient?
• can the local health service provide the intervention/diagnostic test?
• what are the benefits and costs?

Question 499

What do randomised control trials look at?

Answer 499

Look at new treatment, often a drug - compares to current gold standard or placebo

Question 500

How is randomisation done?

Answer 500

• enveloped
• computer system