Lecture notes H&S Flashcards

Question

Epidemiology

Answer 1

‘Study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems’

Answer 2

* Aetiological hypotheses * Prevention * Health service planning and evaluation

Answer 3

Rate at which new cases of cancer occur during a specified time in a defined population Often reported as numbers of cases * In the world 19.2 million people were diagnosed with cancer in 2020 * 201 cases per 100,000 person-years

Answer 4

Measures the burden of disease in a population

Answer 5

* Age distribution of populations * Competing causes * Healthcare factors – Screening, Reporting mechanisms * Differences in aetiological factors

Answer 6

* Associated with 50% to 60% of all cancer deaths * Causally linked to cancers of the lung, upper respiratory tract, oesophagus, bladder, pancreas * Probably a cause of cancer of the stomach, liver, kidneys, colon, and rectum

Answer 7

* 1:2 lifetime incidence * 1:4 die of cancer * Over 375,000 people in England are diagnosed with cancer every year * 167,000 die each year from cancer * At least 2.5 million people are living with and beyond a cancer diagnosis. * Cancer incidence in many tumours rising * Cancer mortality declining

Answer 8

* Despite methodological limitations - in the UK in the 1980s and 1990s cancer survival was one of the worst in Europe * Expert Advisory Group formed in 1995 and generated the “Calman-Hine” report

Answer 9

* All patients to have access to a uniformly high quality of care * Public and professional education to recognise early symptoms of cancer * Patients, families and carers should be given clear information about treatment options and outcomes * The development of cancer services should be patient centred * Primary care to be central to cancer care * The psychosocial needs of cancer sufferers and carers to be recognised * Cancer registration and monitoring of outcomes essential

Answer 10

1. Primary care 2. Cancer Units Serving DGHs a. Treating Common Cancers b. Diagnostic procedures c. Common Surgery d. Non-Complex chemotherapy 3. Cancer Centres – population of 1,000,000+ a. Treating Rare cancers b. Radiotherapy c. Complex chemotherapy

Answer 11

* Modern management of cancer involves many disciplines surgical and non-surgical oncology * Gold standard of treatment for cancer * Allied Health professionals e.g. nurses, physiotherapists, speech therapists etc also play an important role * Delivery of cancer care is often fragmented over several hospital sites. Therefore, there is a need to streamline and co-ordinate various components of care * Probably better outcomes for patients managed in MDTs

Answer 12

Core Medical Staff: * Physician * Surgeon * Oncologist * Radiologist * Histopathologist * Specialist Nurses * MDT co-ordinator Extended * Physiotherapist * Dietician * Palliative care * Chaplain

Answer 13

* To discuss every new diagnosis of cancer within their site * To decide on a management plan for every patient * To inform primary care of that plan * To designate a key worker for that patient * To develop referral, diagnosis and treatment guidelines for their tumour sites according to local and national guidelines * Audit

Answer 14

* To save more lives * To ensure people with cancer get the right professional support and care as well as the best treatments * To tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals * To build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics revolution, so that the NHS never falls behind in cancer care again.

Answer 15

* NHS plan covered the broad concepts of prevention, screening, diagnosis, treatment and organisation of cancer services * NHS plan was followed by several Improving outcomes guidance’s (NICE) which related to the organisation of services for a particular cancer * 2000 Manual of cancer standards over 300 standards relating to the delivery of cancer treatment including provision of chemotherapy, radiotherapy etc. * 2004 Revised Manual (now called the manual of quality measures) over 900 new measures. * National Peer review

Answer 16

1. Prevention 2. Diagnosing cancer earlier 3. Ensuring better treatment 4. Living with and beyond cancer 5. Reducing cancer inequalities 6. Delivering care in the most appropriate setting

Answer 17

* Prevention and early diagnosis * Quality of life and patient experience * Better treatments * Reducing inequalities

Answer 18

1. Spearhead a radical upgrade in prevention and public health 2. Drive a national ambition to achieve earlier diagnosis (find 95% of cases and refer within two weeks) 3. Establish patient experience as 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, including 6. Overhaul processes for commissioning, accountability and provision

Answer 19

* We are embodied: everything we do is ‘through’ our bodies (Barry and Yuill, 2016:165) * Most of the time we take our bodies for granted as an extension of ourselves * Leder (1990) referred to this as the ‘absent body’ * It is only when the body is sick or in pain that it intrudes on our consciousness, and we become aware of it * This is referred to as the dys-appearance: an awareness of the body when it is “bad” or “ill” (Zeiler 2010)

Answer 20

* A ‘civilised body’ is kept clean and natural functions are hidden * The functions of the body (‘unbounded’) should be hidden and kept separate from public life (urinating, defecating, bleeding, lactation etc.) * Children are taught to control their bodies, which is often a marker of their development and progression to adulthood * Nudity and sex are kept private and away from public spheres * Emotion is often considered bodily (e.g., ‘mind over matter’ or ‘weakness of the flesh’) * Personal space – physical distance between bodies

Answer 21

* Ideas of bodily perfection (usually of women) are powerful influences on health-related behaviour * People attempt to (re)shape their bodies to meet societal ideals through activities such as diet and exercise * Diet has a long history, although it is only since the 20th century that its primary purpose has been aesthetic (Bordo 1990) * Cultural ideas about what makes a body good or attractive carry moral connotations * In this sense our bodies are socialised (shaped by society)

Answer 22

health is the project of the self. Way someone looks + their morals is inspirational

Answer 23

* Negative body image (dysphoria) can contribute to the development of eating disorders * Body image can inform other forms of health-related behaviours (exercise and working out) * Some illnesses change the body and its functions leading to negative body image (e.g., incontinence or sexual function) * Treatments may also leave the body changed (e.g., scarring or hair-loss) * Treatment may seek to restore body image (prosthetics or reconstructive surgery) * Certain disabilities may impact perception of the body

Answer 24

* The Body Appreciation Scale (BAS-2) * The Body Esteem Scale for Adolescents and Adults (BESAA) * The Body Shape Questionnaire * The Centre for Appearance Research Valence Scale * The Drive for Muscularity Scale * The Body Dissatisfaction subscale of the Eating Disorder Inventory-3 (EDI-3) * The Appearance Evaluation subscale and Body Areas Satisfaction Scale

Answer 25

* Self-completed Likert-scale questionnaire * BAS-2 was found to have good reliability and validity (Kling et al 2019) * However there are cultural and gendered differences * Women more likely to interpret questions are being about appearance (Dignard & Jarry 2018)

Answer 26

* A recent development in studied of body image is the interest in looking at body functionality (what a body can do) * Cash and Smolak (2011) argue that functionality is an alternative approach to body image * The emphasis on bodily dissatisfaction (BD) comes from studying eating disorders (pathological) * Functionality is more holistic and applicable to other contexts, such as adapting to an impairment or prosthesis * Functionality is not just physical but sensory, espressive and creative (Alleva et al., 2015)

Answer 27

* Role with family and friends * Confidence and interaction with others * Sexual relationships and intimacy * Employment and hobbies * Concern about public spaces * Social isolation * Sense of self (biographical disruption)

Answer 28

* NHS fetal anomaly screening programme (FASP) * NHS infectious diseases in pregnancy screening (IDPS) programme * NHS sickle cell and thalassaemia (SCT) screening programme

Answer 29

* NHS cervical screening (CSP) programme (age 25-64 years) * NHS breast screening (BSP) programme (age 50-70 years)

Answer 30

NHS abdominal aortic aneurysm (AAA) programme (age 65)

Answer 31

* NHS newborn and infant physical examination (NIPE) screening programme * NHS newborn blood spot (NBS) screening programme * NHS newborn hearing screening programme (NHSP) * NHS diabetic eye screening (DES) programme (age 12 but only for people with diabetes) * NHS bowel cancer screening (BCSP) programme (used to be 60-74 years but has been extended to 56 years with the intention of age 50-74)

Answer 32

* Screening gives the potential for early treatment and better outcomes * In some cases, screening can prevent the onset of disease through preventative treatment (e.g. removal of abnormal cells) * People may not have any symptoms (asymptomatic)

Answer 33

* Condition * Test * Treatment * Programme * Implementation

Answer 34

305,683 in total Cervical cancer incidence: UK (2017-2019): Major risk factor (HPV)

Answer 35

* Jointly commissioned by Cancer Research UK and the Department of Health (2012): Marmot Review * Weighed up the evidence for harms and benefits of breast screening * 20% reduction in mortality among women invited for screening * For every 235 women invited, 1 breast cancer death averted * 19% of breast cancers diagnosed during screening period were ‘over diagnosed’ (Data not strong) * Concluded that breast screening was beneficial * 1% chance of overdiagnosis among women aged 50-52 invited for screening

Answer 36

Support Patient Care * Record of contact with health care providers. * Facilitate communication with and about patients. Improve Future Patient Care * Training of clinicians * Audit * Financial planning * Management * Research

Answer 37

* Support method of, and structure to, history and examination * Ensure clarity of diagnosis * Record treatment plans (hold clinicians accountable) * Record results/investigations (able to monitor trends easily) * Enable comprehensive monitoring * Help maintain a consistent explanation for the patient * Ensure continuity of care- handovers and transfer of records * Storage for correspondence * Transfer the record to any NHS practice with which the patient subsequently registers (GP record) * Assist in the clinical care of the patient population by: * Assessing the health needs * Identifying target groups * Enabling call and recall programmes * Monitoring the progress of health promotion initiatives * Audit

Answer 38

* Support clinical audit * Facilitates clinical governance * Facilitates risk management * Support clinical research -data can be pulled for performance measurement (think audit and remunerations) -accurate and curated data collection due to e-record features

Answer 39

* Audit trail * Patient safety * Manage complaints * Review practice * Support seasonal initiatives eg flu vaccination

Answer 40

* Medication errors * Surgical errors * Hospital-acquired infections * Diagnostic errors * Falls * VTE * Pressure ulcers * Patient misidentification

Answer 41

an unintended event resulting from clinical care and causing patient harm

Answer 42

a situation in which events or omissions, arising during clinical care fail to develop further, whether as the result of compensating action, thus preventing injury to a patient

Answer 43

events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response...

Answer 44

* Human error * System & organisation factors * Technology * Patient-related factors

Answer 45

* Around 1 in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe care. * In low-to-middle income countries, as many as 4 in 100 people die from unsafe care. * Above 50% of harm (1 in every 20 patients) is preventable; half of this harm is attributed to medications. * Some estimates suggest that as many as 4 in 10 patients are harmed in primary and ambulatory settings, while up to 80% (23.6–85%) of this harm can be avoided.

Answer 46

* An estimated 850,000 adverse events each year in the NHS hospital sector * £2 billion direct cost in additional hospital days * 11,000 patients lodged new clinical negligence claims during 2018/19 * Value of clinical negligence claims received in 2018/19 was £4.9bn

Answer 47

* Immediate actions – patient safety * Apologise to the patient – duty of candour * Learn from it – reflect * Report it * Analysis of why it happened – root cause analysis * Change to policies / procedures / other preventative measures

Answer 48

- latent conditions - active failure - defences, barrier, safeguards

Answer 49

* Unfamiliarity with the task* * Inexperience* * Shortage of time * Inadequate checking * Poor procedures * Poor human equipment interface * Especially if combined with lack of supervision

Answer 50

1.. Avoid reliance on memory 2. Make things visible 3. Review and simplify processes 4. Standardize common processes and procedures 5. Routinely use checklists 6. Decrease the reliance on vigilance

Answer 51

1881 – The Midwives Institute formed (from elite group of philanthropic, middle class, upper middle class and aristocratic women) 1902 – Midwives Institute to the The First Midwives’ Act—enshrines normality in childbearing as the midwife’s role, referring to doctors as soon as abnormality occurs

Answer 52

* equal access to midwives and doctors for childbearing women of all socioeconomic standing. * drive out the laity in midwifery the “handywomen” * gatekeepers to midwifery education became physicians’ societies, and the burgeoning obstetric profession.

Answer 53

* Labour diagnosis @2cm * Early artificial rupture of membranes (ARM) * 2 hourly vaginal examinations (VEs) * Syntocinon when progress less than 1cm/hr * And in 2nd stage for descent or weak contractions * Personal ‘nurse’

Answer 54

* Instinctive, innate and primeval (Hypothalamus under limbic cortex) * Eustress - Physically stressful Stimulated by… * Pressure on cervix * Vaginal fullness * Pelvic floor pressure * Crowning

Answer 55

* Anaesthetic injections (Epidural) inhibit Ferguson reflex * Induction/augmentation flooding receptor sites - less sensitivity to natural oxytocin * Poor fetal position – less distention of lower genital tract * Episiotomy - less stretching of perineum * Separation - lack of nipple stimulation * Fear / anxiety - internal & external factors * Indirect - e.g. embarrassment / abuse

Answer 56

Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care. Poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care

Answer 57

Deaths and appalling permanent harm as a direct result of bad clinical decisions, chronic short-staffing and poor attitude Staff relationship breakdowns exposed vulnerable women and their families to unacceptable situations

Answer 58

* Around 1 in 11 children and young people are living with asthma. * The UK has one of the highest prevalence, emergency admission and death rates for childhood asthma in Europe. * The rates of emergency admissions for asthma have been falling since 2003/04 * Emergency admissions are strongly associated with deprivation – the rate of admissions is 2.5 times higher in

Answer 59

* Childhood obesity has increased over the last decades with almost 40% of Year 6 children now overweight or obese * Children living in the most deprived areas are more than twice as likely to be obese than those in the least deprived areas and this gap continues to widen * Children of obese parents are more likely to be obese themselves than children whose parents are not overweight or obese * Obese children are more likely to remain obese in adulthood * Obesity is known to increase the risk of 14 major conditions

Answer 60

* Smoking is largest preventable cause of mortality, morbidity and inequalities in health in England * Smoking during pregnancy can cause serious pregnancy-related health problems e.g. complications during labour and increased risk of miscarriage, premature birth, stillbirth low birthweight and sudden unexpected death in infancy * In 2018/2019 the % of pregnant women who said they were smokers at booking in England was 12.8%, ranging from 2.1% in Kensington and Chelsea to 29.1% in Blackpool * Mothers of white ethnicity were 8.8 times more likely to smoke than women with Asian ethnicity * Women living most deprived deciles were 5.6 times more likely to smoke than women in least deprived

Answer 61

* Children in reception (age 4 to 5 years) living in the most deprived areas in England are more than twice as likely to be living with obesity compared to those living in the least deprived areas. * Children in year 6 (age 10 to 11 years) living in the most deprived areas in England are more than twice as likely to be living with obesity compared to those living in the least deprived areas. * Estimate that between 2014/2015 NHS spent £6.1 billion on obesity related ill health – this is without societal costs

Answer 62

an upstream population level intervention to tackle obesity Government work on Child Obesity Strategy found high proportion of children’s excess calories came from ‘free sugars’ - soft drinks a key contributor Aim was to reduce rising obesity rates and reduce sugar consumption esp in children

Answer 63

It has been effective, particularly in driving industry reformulation Significant reductions in the sugar content of drinks following the levy (in 2019 % of drinks subject to highest bracket fell from 49% to 15%) 3% reduction of sugar purchased per household More effective than voluntary measures at achieving public health goals – should be extended to include milk-based drinks

Answer 64

48% of babies are breastfed at 6-8 weeks, by 6 months 34% of women are breastfeeding, only 1% exclusively Older mothers are more likely to breastfeed than younger mothers Women of white ethnicity least likely to breastfeed than other ethnic groups Women who live in areas with least deprivation 1.5 times more likely to have breastfed their baby than women who lived in areas with highest deprivation

Answer 65

* Breastfeeding idealised as ‘natural’ and ‘best’ * Tension between promoting health benefits and respecting autonomy * Messaging can sometimes feel coercive rather than supportive * Conversely negative public attitudes towards breastfeeding – public harassment! * Stigma against women who can’t or choose not to breastfeed (women feeling marginalised by ‘breast is best’ message) * Some women cannot breastfeed for biological, physiological or psychological reasons * Mothers who struggle to breastfeed experience emotional distress, stress and poor mental health * Association with PND for women who cannot breastfeed due to physical pain

Answer 66

- Public Health Messaging - Enhance Workplace Support - Expand Community Support - Support Mental Health

Answer 67

* The NHS offers a vaccination schedule for children covering diseases such as measles, mumps, rubella (MMR), diphtheria and polio * Vaccinations are critical for preventing outbreaks and protecting public health * Overall UK vaccination coverage is high, with rates exceeding 90% for primary vaccinations in children aged 1 year1 * Coverage of the MMR vaccine (first does by age 2) is around 89%, below the 95% target needed for herd immunity1

Answer 68

1. The right to safety 2. The right to be informed 3. The right to choose 4. The right to be heard

Answer 69

1. The right to satisfaction of basic needs 2. The right to redress 3. The right to consumer education 4. The right to a healthy environment

Answer 70

1. The right to satisfaction of basic needs – access to health care 2. The right to safety – first, do no harm 3. The rights to be informed, to consumer education, to choose – Informed consent, good choices need good information – agency relationship (pt relies on doctors to give good advice based on their best interest) 4. The right to be heard, the right to redress, patient voice and legal framework 5. The right to a healthy environment – regulators of health care – providing reassurance and monitoring quality

Answer 71

1942 Beveridge report

Answer 72

1. That it meets the needs of everyone 2. That it be free at the point of delivery 3. That it be based on clinical need, not ability to pay

Answer 73

- A large majority agree that the NHS should be available to everyone (82%) - free of charge (91%), - primarily funded through taxes (82%).

Answer 74

Mid-Staffordshire – “the worst hospital care scandal of recent times” Claims (disputed) that between 400 and 1,200 patients died because of poor care between 2005 and 2009 at Stafford hospital

Answer 75

* Bristol Royal Infirmary – high death rates in paediatric cardiac surgery * Inquiry found "staff shortages, a lack of leadership, [a] unit ... 'simply not up to the task' ... 'an old boy's culture' among doctors, a lax approach to safety, secrecy about doctors' performance and a lack of monitoring by management

Answer 76

Individual doctor scandals – Rodney Ledward, Richard Neale, Roger Bainton (botched operations) Harold Shipman – GP and serial killer (convicted of 15 murders, likely to be around 250 or more) – another legal inquiry Ian Paterson – the ‘butcher surgeon’ – currently in prison convicted of wounding with intent and unlawful wounding Michael Watt – Belfast neurologist – ‘stark, serious and repeated failures’ with 5000 patients recalled – struck off and now under police investigation

Answer 77

* poor clinical monitoring * diagnostic errors * inadequate drug & fluid management in near equal parts

Answer 78

1. acts of omission (e.g. failure to treat according to best evidence) 2. acts of commission (e.g. incorrect treatment or management) 3. unintended harm due to complications of care

Answer 79

US error rates of 3-5% means that: * Medical errors in hospitals kill 44,000-98,000 Americans each year * Errors kill more Americans than motor vehicle accidents (43,458), or breast cancer (42,297) or AIDS (16,516) * Medication drug errors in the USA annually kill three times the number killed at 9/11 * Medical errors still the third leading cause of mortality in the USA, (Makary & Daniel, BMJ, 2016.

Answer 80

1. Medication – wrong drug, wrong dose 2. Surgery – wrong procedure or other failures (surgical “check lists”) 3. Infection control

Answer 81

1. Weapons 2. Food 3. Trust If a ruler can’t hold on to all three, he should give up weapons first and food next. Trust should be guarded to the end “without trust we cannot stand”

Answer 82

* Patient Advice and Liaison Services in all hospitals * Well-defined complaints procedures and a ‘duty of candour’ * Despite this, increasing costs of litigation against the NHS Clinical negligence costs of £2.8 billion in 2023/24

Answer 83

* Regulates “quality” of all health and social care providers, public and private. * Licensing all providers of health and social care * Policing: unannounced visits and use of routine data (HES)

Answer 84

The SHMI is the ratio between the actual number of patients who die following hospitalization at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. It covers patients admitted to hospitals in England who died either while in hospital or within 30 days of being discharged.

Answer 85

82% of adult social care services were rated as good or outstanding. 95% of GP practices were rated as good or outstanding. 70% of NHS acute core services were rated as good or outstanding. 73% of all mental health care services (NHS and independent) were rated as good or outstanding.

Answer 86

1. Hospital episode statistics (HES) 2. Patient reported outcome measurement (PROMs)

Answer 87

Health Security Agency - role is to protect the health and well-being of the population by e.g. monitoring infection rates GMC - regulates Medical Schools and the registration of practitioners Royal colleges - regulates Medical Schools and the registration of practitioners

Answer 88

* respond to Category 1 calls in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes * respond to Category 2 calls in 18 minutes on average, and respond to 90% of Category 2 calls in 40 minutes

Answer 89

the length of time a patient waits from referral to the start of treatment

Answer 90

92% of people waiting for elective treatment should wait no longer than 18 weeks from referral to their first treatment.

Answer 91

52 weeks from referral to first treatment

Answer 92

Recent analysis highlighted the disparity in waiting times around the country and a correlation with deprivation, identifying that on average a person living in one of the most deprived areas is 1.8 times more likely to wait over a year than someone living in one of the least deprived areas.

Answer 93

* 28-days wait from an urgent referral to patient told whether they have cancer or cancer is excluded * 75% target

Answer 94

* Pressure on services * Oct 2024 – 2.36m A&E attendances * Backlog of care * Workforce shortages * Poor patient flow * High bed occupancy (>90%) * Social care

Answer 95

only 24% of the public are satisfied with the NHS

Answer 96

1. Waiting times 2. Staff shortages 3. Funding

Answer 97

(Blythe & Ross, 2022) Supply & demand Challenges: 1. Weak evidence 2. Associations not causation

Answer 98

1. Uncertainty 2. Prologued suffering 3. Potential deterioration i. More complicated treatment required / more medication ii. Slower recovery & worse outcomes 4. Reduced QoL? – Loss of independence 5. Support? – Impact on relatives

Answer 99

a relationship between an exposure and an outcome is distorted by their shared relationship with something else.

Answer 100

Confounding could: 1. Increase the apparent association between exposure and outcome 2. Decrease the apparent association between exposure and outcome

Answer 101

1. Restriction 2. Matching 3. Stratification 4. Multiple variable regression 5. Standardisation

Answer 102

1. There is no association between exposure and confounder 2. There is no association between confounder and outcome 3. The additional variable is on the causal pathway between Exposure and Outcome

Answer 103

1. Personal experience is biased in various ways 2. Research reports findings for more patients than we can see in personal experience 3. Research involves the application of scientific method: 4. testing of hypotheses, systematic data collection, analysis -designed to minimise bias 5. Recommendations have been assessed for their clinical and cost effectiveness in the NHS

Answer 104

1. Interactive and iterative 2. Engage participants across organisational levels 3. Foster environment where improvement and innovation are viewed as normal 4. Empowering staff to strive for change 5. Provide knowledge and methods to implement change 6. Remove barriers to change

Answer 105

1. Educational meetings 2. Local consensus processes to identify or prioritise interventions 3. Educational outreach visits 4. Local opinion leaders 5. Reminders (written, verbal) 6. "Tailored" approaches, such as focus groups or surveys, to identifying specific barrier

Answer 106

Dementia is the name for a group of symptoms that commonly include problems with: * Day-to-day Memory * Thinking and concentrating * Problem-solving and planning * Language and communication * Visual Perception * Changes in mood

Answer 107

In 2021 there were an estimated 55 million people living with dementia worldwide. * 850,000 of these are in the UK * 60% living in low- and middle-income countries. * This number is expected to rise to 78 million in 2030 and 139 million by 2050.

Answer 108

1. Numbness 2. Yearning/pining and anger 3. Disorganisation and despair 4. Reorganisation

Answer 109

1. Somatic or bodily distress 2. Preoccupation with the image of the deceased 3. Guilt relating to the deceased or circumstances of the death 4. Hostile reactions 5. Inability to function as one had before the loss 6. Development of traits of the deceased in own behaviour

Answer 110

Sadness, anger, guilt & self-reproach, anxiety, loneliness, fatigue, helplessness, shock, yearning, emancipation, belief, numbness Somatic sensations from stomach, chest, throat, sensitivity to noise, depersonalisation, breathlessness, muscle weakness, lack of energy, dry mouth Disbelief, concentration impairment, preoccupation with the deceased, sense of presence, hallucinations

Answer 111

1. Accept the reality of the loss 2. Work through the pain of grief 3. Adjust to an environment in which the deceased is missing 4. Emotionally relocate the deceased and move on with life

Answer 112

* Secure attachment * Anxious ambivalent/resistant attachment * Anxious avoidant attachment * Disorganised attachment

Answer 113

1. Belief in an afterlife (BA) – the continuing existence of the loved one and possibility of meeting up again 2. Continued attachment (CA) – prayer as means of continuing connection with the deceased 3. Defence against fear of personal death/extinction 4. Religious funeral rituals that aid and progress the grief process 5. Religious funeral rituals that recruit social support

Answer 114

* Good patient care * And feedback * Job satisfaction * Palliative medicine principals applied to all of medicine * Exam questions

Answer 115

Palliative care is the active holistic care of patients with advanced, progressive illness.

Answer 116

1. Holistic needs assessment and provision of basic symptom control 2. Referral to specialist palliative care if appropriate

Answer 117

Generalist: 1. Primary health care team 2. Nursing home 3. Secondary care 4. Social services Specialist: 1. Clinical nurse specialists (community and hospital) 2. Specialist physicians in palliative care 3. Hospices 4. Marie Curie nurses

Answer 118

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

Answer 119

* Air pollution – Outdoor, Indoor * Climate Change * Environmental disasters * Occupational exposures

Answer 120

* Worldwide 4.2 million premature deaths in 2016 * Mainly due to PM2.5 (those with a diameter of 2.5 microns or less) * Disproportionate morbidity in low- and middle-income countries * Deaths are due to IHD/stroke (58%), COPD (18%), lung cancer (6%)

Answer 121

1. Particulate Matter * A mix of solid and liquid droplets arising mainly from fuel combustion and traffic * This has the greatest impact on peoples’ health 2. Nitrogen dioxide * Arising mainly from road traffic and indoor gas cooking 3. Sulphur Dioxide * Arises mainly from burning fossil fuels * Associated with asthma and poor lung function 4. Ozone * Caused by the reaction of sunlight with pollutants from vehicle emissions

Answer 122

A mix of solid and liquid droplets in the air - e.g. soot, recondensed metallic vapours, organic debris

Answer 123

* Worldwide smoke fires used for cooking. * Biomass fuels produce large amounts of particulate matter * Probably contributes to COPD and childhood respiratory infection Second and third hand tobacco smoke exposure has health consequences.

Answer 124

* Underdiagnosed * Commonest cause of occupational lung disease in UK * Over 200 causes * Early recognition important * Interaction with smoking and atopy

Answer 125

A term referring to lung disease resulting from inhalation of dusts. Common types of pneumoconiosis include: 1. Coal workers pneumoconiosis 2. Silicosis 3. Asbestosis

Answer 126

Estimated to cause 10% of lung cancers in men Asbestos estimated to cause 60% of these but unclear whether must cause fibrosis (asbestosis) first or direct effect Also arsenic, chromium, coal gas, coke production, cadmium, chloromethyl ethers, silica, radon, soot

Answer 127

Association between psychosocial distress and CVD risk is well established (Hamer et al., 2008; Rasul et al., 2005; Stansfeld et al., 2002) Psychological stress is comparable to conventional risk factors such as hypertension, obesity, and physical inactivity (Yusuf et al., 2004)

Answer 128

1. Anxiety 2. Depression 3. Anger/Hostility

Answer 129

1. Social support 2. Socioeconomic status (SES) 3. Work/Marital Stress 4. Caregiver strain

Answer 130

Psychological stress – composed of threats to the physical or psychological threats to the individual Fight or flight response – Increase HR, BP, cortisol Creates anticipatory phase  think about it more often = increased physiological response

Answer 131

Stress occurrence leads to dynamic and reciprocal process of cognitive appraisals, affecting emotional choices and behaviours (Lazarus & Folkman, 1984) 1. Primary Appraisal… Challenge? Threat? Harm? Benefit? 2. Secondary Appraisal… Resources available? Usefulness of Coping strategies?

Answer 132

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Answer 133

Loss-orientation – process of dealing with the loss of experience itself (feelings) Restoration-orientated – focuses on what needs to be dealt with, how its dealt with. (adjustments)

Answer 134

Defined as heart complaints for which no organic cause can be found * cardiac anxiety neurosis, cardiac anxiety disorder, cardiac phobia, functional heart complaints

Answer 135

* “Irritable heart”, “soldier’s heart” * Characterised by dyspnoea, fatigue, rapid pulse, palpitations and chest pain, occurring mostly with exertion * Associated with exhaustion and emotional strain

Answer 136

a pathological condition resulting from a prior disease, injury, or attack. (what happens after the event)

Answer 137

likened to psychological responses * Emotional/Affective * Cognitive/Thoughts * Behavioural/Lifestyle

Answer 138

* Personality – Type A behaviour/Mental Toughness/Hardiness * Existing Psychopathology * Anxiety/Depression * Psychoneuroimmunology (PNI)/stress * Personal control – locus of control. Effect how people take responsibility * Self-efficacy * Social support

Answer 139

an individual’s view of whether they are a candidate for a particular illness/condition and treatment of that condition Why those in more deprived individuals make less use of the services

Answer 140

- Age - Gender - Social deprivation/SES - Co-existing physical illness and severity - Health and illness beliefs - Intelligence / Education - Past family history (lifestyle not genes - empower the patient) - Other people (family/workmates/neighbours) - Culture (cultural restrictions on exercise/diet) - The Media

Answer 141

Based on a normative theory of decision making subjective expected utility theory (SEUT)

Answer 142

1. Decision processes are logical and rational 2. A rational decision maker will choose the option to maximise utility (the desirability or value attached to a decision outcome)

Answer 143

* Assists in understanding a decision task * Divides decision task into components * Uses decision trees to structure the task * Uses evidence in the form of probabilities, so can examine the risks (or chance) associated with each option * Examines the utility or cost associated with each option * Suggests the most appropriate decision option for that situation

Answer 144

Decisions are based on evidence, not anecdote, narrative or impression ‘Evidence’ is empirical (generated by research) DA draws on evidence of effectiveness (from RCTs) and prognosis (from RCTs or cohort studies) It also draws on values attached to outcomes which are derived from the patient, or groups of patients, or health economics

Answer 145

* EBM is often dominated by methodological ‘rules’ * Key aim is to reduce bias & increase rigour * But these ‘rules’ and the research that underpins them are not value-free * Patient values are integral to EBM but have received little systematic attention

Answer 146

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

Answer 147

Square node * Decision node * Represents choice between actions Circle node * Chance node * Represents uncertainty * Potential outcomes of each decision

Answer 148

* Use probability (chance) of events occurring * For each ‘branch’ in the decision tree, values must total 1.0 or 100% Specific measures of the uncertainty associated with the decision * Highlights the risks associated with each decision option * Probabilities should come from good quality research evidence

Answer 149

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

Answer 150

commonly used for population utility measures (e.g. in generating incremental cost-effectiveness ratios) * 1 year in perfect health = 1 QALY. * Health states measured against this (e.g. 2 years in health rated as 0.5 of perfect health = 1 QALY). * Considers quantity and quality of life.

Answer 151

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

Answer 152

* Necessary if numbers in the analysis are uncertain * Can the effect different values will have on an outcome * Known as sensitivity analysis * Done by varying uncertain variables over a plausible range * Can calculate the effect of uncertainty on decision

Answer 153

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

Answer 154

Probability estimates * Required data sets to estimate probability may not exist * Subjective probability estimates are subject to bias: over-confidence & heuristics (biases) Utility measures * Individuals may be asked to rate a state of health they have not experienced * Different techniques will result in different numbers * Subject to presentation framing effects (e.g. survival / death) * The approach is reductionist (e.g. stroke outcomes as binary: ‘affected’ or ‘unaffected’)

Answer 155

* Uses evidence in the form of probabilities, and * Examines the utility (or cost) of each option

Answer 156

Probability of an event in each time

Answer 157

is the risk of disease in the exposed group / risk of disease in unexposed group. When interpreting this, it is seen to be risk in the exposure is XXX amount times HIGHER than compared to the unexposed group.

Answer 158

is the risk rate in the exposed group MINUS the risk rate in the unexposed group. This is interpreted as the EXCESS number of cases in the exposed group compared to the unexposed. How many EXCESS cases there are.

Answer 159

How much of the disease in the population is attributable to a particular exposure

Answer 160

risk in population - risk in unexposed

Answer 161

What proportion of disease in the population is attributable to a particular exposure?

Answer 162

risk in population - risk in unexposed DIVIDED by risk in general population

Answer 163

1. blood pressure 2. cholesterol 3. smoking

Answer 164

“A preventive measure that brings large benefits to the community offers little to each participating individual” – Geoffrey Rose (1981)

Answer 165

Objective – a reduction in disease incidence e.g. * Increase exposure to protective factors (e.g. vaccination) * Reduce exposure to ‘risk factor(s)’ e.g. * Modify personal behaviour (e.g. stop smoking) * Change/improve services to the population (e.g. clean water) Strategies: 1. Mass or population (whole population) 2. High-risk (sub-groups of the population)

Answer 166

Objective – Target those at high risk for the disease Identify those at high risk and move them to lower levels

Answer 167

Objective – Reduce the burden of disease across the entire population Modification of population behaviour or parameter

Answer 168

1. Appropriate to individual 2. Motivated subject 3. Motivated clinician 4. Cost-effective resource use 5. Benefit: Risk – High

Answer 169

1. Screening difficult 2. Palliative & temporary 3. Limited potential 4. Labelling

Answer 170

large potential

Answer 171

1. Population Paradox – small individual benefit 2. Poor motivation 3. Benefit:Risk – Low

Answer 172

* NOT a step difference in the relationship with disease * Weighing the balance between costs and benefits – Absolute benefits (no. of deaths prevented) – Costs to individuals (another tablet?) – Costs to populations (another million tablets?) – Absolute harms (no. of people harmed)