Metabolic Flashcards
(83 cards)
1
Q
Outline the guidance for preventing AKI in patients currently admitted in hospital
A
- identify those at risk by monitoring NEWS score.
- recognise and respond to oliguria in those at risk.
- measure U&Es in those at risk.
- record weight daily to determine fluid balance in those at risk.
2
Q
Outline the guidance for preventing AKI in adults having iodine-based contrast media
A
- encourage oral hydration before and after procedure.
- IV volume expansion with isotonic sodium bicarbonate or 0.9% sodium chloride in high risk inpatients.
- temporarily stop ACEi and ARBs in adults with CKD eGFR < 40.
- discuss with nephrology team before.
3
Q
Outline the guidance for preventing AKI in people at high risk/preventing deterioration
A
- electronic clinical decision support systems (CDSS) to support decision making and prescribing.
- seek advice from pharmacists about optimising medicines and drug dosing.
- temporarily stop ACEi or ARBs in patients with D+V or sepsis.
4
Q
Describe the impact of haemodialysis on a patient’s physical/social well-being and psychological health
A
- the time the patient has to go for dialysis will restrict their activities and social interaction.
- reduces flexibility in a patient’s schedule e.g. going abroad or working.
- patient might find fluid restriction tedious and negatively impact on mental health and social life.
- AV fistula might make patients self-conscious and have a negative impact on body image.
- home dialysis/self-care is more flexible and empowering.
5
Q
Describe the impact of peritoneal dialysis on a patient’s physical/social well-being and psychological health
A
- patient might find fluid restriction tedious and negatively impact on mental health and social life.
- PD tube might impact negatively on body image.
- risk of peritonitis.
- more flexibility on when to dialyse, improves patient’s social and work life. Can dialyse at night.
- treatment everyday rather than 3x per week.
6
Q
What is the role of the Human Tissue Act (2004)?
A
To regulate the removal, storage and use of human tissue, to ensure its safe and ethical use.
7
Q
What is the main change that came about in the Human Tissue Act (2004)?
A
It replaced the Human Tissue Act 1961, the Anatomy Act 1984 and the Human Organ Transplants Act 1989. The main change was focused around consent for the removal, storage and use of human tissue from living or deceased donors. It established the Human Tissue Authority (HTA).
8
Q
Describe the offences under the Human Tissue Act (2004)
A
- Removing, storing or using human tissue for Scheduled Purposes without appropriate consent.
- Storing or using human tissue donated for a Scheduled Purpose for another purpose.
- Trafficking in human tissue for transplantation purposes.
- Carrying out licensable activities without holding a licence from the HTA.
- Having human tissue, including hair, nail, and gametes, with the intention of its DNA being analysed without the consent of the person from whom the tissue came or of those close to them if they have died.
9
Q
Considering the 4 principles of medical ethics, which does the Human Tissue Act (2004) aim to uphold?
A
Non-maleficence: not harming human tissue, ensuring it’s safety.
Justice: fair and ethical use of human tissue.
10
Q
What has been the implication of the Human Tissue Act for Organ Transplantation?
A
It requires that every living transplant donor and recipient is assessed by a formally trained and HTA‐accredited third party. The HTA will then pass judgment on the potential donation.
11
Q
What is the role of the Human Tissue Authority (HTA)?
A
Regulatory body under the Human Tissue Act (2004) that regulates the removal, storage and use of human bodies, organs and tissue from the deceased and the storage and use of human organs and tissue (excluding gametes and embryos) from the living. It is also responsible for assessing applications for organ donation from living people.
12
Q
Describe the role of the independent assessor (IA) for organ donation
A
All donors and recipients see an IA who is trained and accredited by the HTA to ensure that the donor has given valid consent, without coercion, and that reward is not a factor for the donation. They also ensure the donor has the capacity to make an informed decision. Donors and recipients must bring prof of their identity and relationship. IA then approves living donation.
13
Q
Whose responsibility is it to seek consent for the removal of organs, for the purpose of transplantation?
A
It is the responsibility of the treating clinician.
14
Q
What are the two kinds of risks that an individual should be aware of before agreeing to donate organs?
A
Generic risk - any reasonable person or all donors would attach significance.
Individual risk - the person consenting to donation would attach significance (specific to the donor).
15
Q
Before giving approval for organ donation, which 3 key conditions are required by the HTA?
A
- No reward has been, or will be, given.
- Consent to removal, for the purpose of transplantation as been given.
- An independent assessor has conducted separate interviews with the donor and recipient and submitted a report of their assessment to the HTA. A joint interview with donor and recipient is also required (except with non-directed altruistic donors).
16
Q
If the organ donor is a child, how is the decision of whether transplantation proceeds made?
A
Made by a HTA panel of at least 3 members in all cases where there is perceived to be a higher regulatory risk e.g. if the organ donor is a child.
17
Q
“The HTA also requires the living donor to specify how they wish their donated organ or part organ to be used should it not be possible to transplant it into the intended recipient”. What are the different options available to the donor? When is this decision usually made?
A
- Donor is ask to consent to either: implantation into another recipient, re-implantation back into the donor, research, or disposal of the organ.
- Consent for this is taken during discussion with the surgeon.
18
Q
What does the Human Tissue (Scotland) Act 2006 suggest with regards to the use of human tissue?
A
- Provision for activities involving human tissue in the context of transplantation, research and education, its removal, retention and use following post-mortem examinations.
- Provisions are based on authorisation rather than appropriate consent.
19
Q
How does altruism relate back to living donor transplantation?
A
Reinforces the philosophy of voluntary and unpaid donation and solidarity between donor and recipient.
20
Q
How does autonomy relate back to living donor transplantation?
A
Entitlement to control our own body and to the right of self-determination. Therefore valid consent must be given by the living donor before an organ can be removed, which must be made freely and autonomously. Donor has the right to make the decision to donate their organs.
21
Q
How does beneficence relate back to living donor transplantation?
A
Donation must be in the patient’s best interests.
22
Q
How does dignity relate back to living donor transplantation?
A
Any form of financial payment or commodification of bodies or body parts violates human dignity (honour/respect).
23
Q
How does non-maleficence relate back to living donor transplantation?
A
Transplantation should not involve harm to the donor or recipient.
24
Q
How does reciprocity relate back to living donor transplantation?
A
It refers to providing benefits or services to another as part of mutual exchange, for example in paired/pooled donation.
25
Describe the possible ethical dilemmas that may arise for the recipient
- Living donor transplant is the preferred option rather than deceased donation as the survival rates are better, however this might not always be available (justice).
- Living donation can only be justified if the interests of the donor are given priority, regardless of recipient benefit.
26
Describe the possible ethical dilemmas that may arise for the donor
- Even though there are overall benefits for the individual donor and wider society, living donor still entails risk, including a small risk of death. Is it fair to risk the life of the donor to save the life of the recipient?
- Removal of kidney may cause physical harm on health and well-being. This conflicts with non-maleficence.
- Questionable whether informed consent for organ donation can truly be given, with all the risk of donation (does the donor listen?).
- The only person who can know that consent is ‘freely given’ (voluntary) is the living donor. Subtle pressures from family members may not be revealed and remain undetected. Overt pressure or coercion is easier to identify.
- Difficult to establish that consent is both informed and voluntary.
27
Describe the possible ethical dilemmas that may arise for the transplant team
- If MDT has concerns about suitability of a potential donor and that it may be inappropriate (e.g. too risky), they are under no obligation to proceed, even if the donor wishes to proceed. Conflicts with donor autonomy.
- When is it appropriate to remove patients from national transplant list for deceased donor kidney if they have a potential living donor undergoing assessment? Balance the needs of the recipient, potential donor and the ‘greater good’ to the pool of patients waiting for a kidney (justice).
28
When did the opt-out organ donation system come into place and what does it mean?
- 20th May 2020.
- All individuals over the age of 18 are considered as organ and tissue donors unless they have opted out, have appointed a representative to decide for them after death or are in one of the excluded groups (<18, ordinarily resident in England for <12 months before their death, or lack mental capacity for a significant period before their death).
29
Describe the arguments for the opt-out organ donation system
- Increases the number of donors as there was a shortage of available organs in England.
- Reduces mortality rates in those waiting for a transplant.
- Makes the waiting list time shorter.
- Still respects patient autonomy.
30
Describe the arguments against the opt-out organ donation system
- People might not be aware of the law change, so might donate organs against their wishes when they are deceased.
- People might not know which organs are routinely transplanted and might only allow certain organs to be donated. Therefore people may wish to opt-out of certain body parts.
- Some individuals might not have access to the electronic opt-out system. Hard-to-reach groups might not engage with the system to express their wishes.
- Consent is an active process and cannot be ‘presumed’ because no objection is known.
31
What circumstances is the opt-out law not valid?
Novel or rare transplants (the law only applies to routine transplants).
32
Outline the role of the MDT in managing the process of organ donation and transplantation
- MDT responsible for planning the approach and discussing organ donation with those close to the patient.
- MDT includes: medical and nursing staff who care for the patient, specialist nurse for organ donation, local faith representative where relevant.
- Continuity of care.
- Provide support and accurate information about organ donation to the patient.
33
Summarise the cost-effectiveness of renal transplantation as opposed to dialysis
- Cost of dialysis is greater than benefits compared to renal transplantation, taking into account QoL (e.g. dietary restrictions, social limitations), emotional/mental effects, long-term financial costs, risk of death, adverse effects.
- Therefore transplantation is the most cost-effective renal replacement modality.
34
How are organs rationed?
- Waiting lists.
- Patients prioritised based on urgency/need, age, blood group/matching, fitness of recipient.
- Opt-out system.
35
Describe the the matching process for organ donation
- Blood group ABO systems.
- HLA-type matching according to the number of mismatches at A, B and DR.
36
Define screening
Identification of people who are at increased risk of developing a disease by systematic application of a test.
37
In terms of prevention methods, is screening primary, secondary or tertiary prevention?
Secondary prevention.
38
What is sensitivity and how do you calculate it?
Proportion of affected individuals correctly identified by the test.
Sensitivity = true positives / (true positives + false negatives).
39
What is specificity and how do you calculate it?
Proportion of unaffected individuals correctly identified by the test.
Specificity = true negatives / (true negatives + false positives).
40
What is PPV and how do you calculate it?
Proportion of positive tests that are correct.
PPV = true positives / test positives.
41
What is NPV and how do you calculate it?
Proportion of negative tests that are correct.
NPV = true negatives / test negatives.
42
Name and define the 2 biases associated with screening
- Lead-time bias: survival time appears longer because diagnosis was done earlier, irrespective of whether the patient lived longer.
- Length-time bias: overestimation of survival duration due to the relative excess of cases that are slowly progressing, while fast progressing cases are detected after giving symptoms.
43
Name the 2 problematic outcomes associated with screening
- Overdiagnosis: diagnosis that otherwise wouldn’t have been made in a patients life time and wouldn’t have caused any harm.
- Overtreatment: unnecessary tests and treatment as a result of screening.
44
Which groups are more at risk from prostate cancer/dying from prostate cancer?
FHx or African descent.
45
Name the risks associated with prostate biopsy
Pain, bleeding, infection, urinary retention, erectile dysfunction (rare), blood in semen/urine.
Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area.
46
Does PSA screening lead to an increased detection of prostate cancer?
It leads to an increased detection of prostate cancer, but no difference in prostate cancer mortality. Also PSA screening leads to overdiagnosis of prostate cancer.
47
What are the side effects of treatment for prostate cancer?
Urinary incontinence, erectile dysfunction, tiredness, tender skin, loss of pubic hair, diarrhoea.
48
Why does a systematic review not support the use of PSA as a screen for prostate cancer?
Because no significant difference in prostate cancer-specific mortality was observed in men randomised to PSA screening compared with men receiving care by standard practice without screening. Also, detection of low risk prostate cancer was greater in PSA screening group (overdiagnosis).
49
Name the 3 criteria of a screening test
- The test should be simple, safe, precise and validated.
- There should be suitable cut-off values defined for the test.
- There should be further diagnostic investigations available for individuals with a positive test result.
- Benefits of test should outweigh the risks.
50
What were the results of the CAP trial 10 years post follow up?
The single PSA screening intervention detected more prostate cancer cases than control group but had no significant effect on prostate cancer mortality after a median follow-up of 10 years.
51
Does early detection of prostate cancer correlate with a clinically beneficial outcome? How does this apply to appraisal criteria of a screening programme?
Detection of prostate cancer at an early stage does not necessarily correlate with a clinically beneficial outcome (such as decline in morbidity or mortality). Early detection subjects some patients to risks associated with treatment unnecessarily. This contradicts the criteria of a screening programme that the test must reduce disease-specific morbidity and/or mortality by detecting cancer at an early stage.
52
How has over diagnosis of prostate cancer been suggested?
It is estimated that 23-50% of prostate cancer diagnoses were likely overdiagnosed, by detecting early stage disease.
53
What is the most widely accepted cut off point for PSA level?
PSA of ≥4.0 ng/mL
54
What is the sensitivity and specificity of the test at this cut off level?
PSA cutoff of 4.0 ng/mL had a sensitivity of 21% and specificity of 91% for detection of any prostate cancer.
55
What happens to sensitivity and specificity of this test if the cut-off point is lowered? What are the implications of this?
- Lowering cut off improves sensitivity, meaning less cases are missed.
- Lowering cut off worsens specificity, leading to greater overdiagnosis and overtreatment.
56
Name the diagnostic tests for diabetes
- Random venous plasma glucose concentration ≥ 11.1 mmol/l
- Fasting plasma glucose concentration ≥ 7.0 mmol/l
- Oral glucose tolerance test
- HbA1c ≥ 48 mmol/mol
57
How many tests are required if the patient is a) symptomatic and b) asymptomatic?
- a) random venous plasma glucose or fasting plasma glucose or oral glucose tolerance test or HbA1c
- b) diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load. If the fasting random values are not diagnostic the two hour value should be used. Laboratory venous HbA1c should be repeated in patients without symptoms
58
In which situations is HbA1c not appropriate for the diagnosis of diabetes?
- All children and young people.
- Patients of any age suspected of having T1D.
- Patients with symptoms of diabetes for < 2 months.
- Patients at high risk who are acutely ill.
- Patients taking medication that may cause rapid glucose rise e.g. steroids, antipsychotics.
- Pregnancy.
- Presence of genetic, haematologic and illness-related factors that influence HbA1c and its measurement.
59
Describe the 9 recommended care processes for diabetes
1. HbA1c optimum level between 6.5-7.5%
2. BP < 140/80mmHg with no kidney, eye or cerebrovascular damage; < 130/80mmHg with evidence of kidney, eye or CV damage.
3. Total cholesterol <= 5mmol/L.
4. Urinary albumin < 2.5 mg/mmol for men and < 3.5 mg/mmol for women.
5. Serum creatinine > 150 micromol/L - discontinue metformin.
6. BMI between 18.5-29.9
7. Check smoking status at annual review.
8. Eye examination annually.
9. Foot examination annually.
60
List some education programmes available for patients with diabetes
- DAFNE, DESMOND, XPERT.
- Carbohydrate counting in patients with T1D.
- Advise on nutrition and exercise.
- All patients with diabetes should be offered a structured education programme within 6-12 months of diagnosis.
61
Outline requirements of T1D specialist services
- Consultant delivered, specialist MDT support for the patient.
- Each patient should have a named type 1 diabetes consultant and diabetes specialist nurse.
- Offered an annual review with the team.
62
Name the members of a community MDT for diabetes care
Consultant diabetologist, GP, diabetes specialist nurse, diabetes specialist dietician, community podiatrist, psychologists.
63
Give examples of services that can be delivered by the community based MDT
- Patient education programmes.
- Pregnancy advice for women of childbearing age.
- Foot protection team.
- Clinical psychology support.
- Additional support for those with T2D and poor glycaemic control.
64
Give examples of services that can be delivered by the specialist care MDT
- Transition service working with paediatric services.
- Diabetes foot service.
- Diabetes antenatal service.
- T1D service, including insulin pump service.
- Diabetes inpatient service.
- Diabetes mental health service.
- Specialist learning disability service.
- Diabetes kidney disease service.
- Diagnostic service where there is doubt as to type of diabetes.
65
Summarise the results from the UK Prospective Diabetes Study (UKPDS) about benefits of BP control and glycaemic control in T2D
- 5,102 patients with newly diagnosed T2D followed for 10 years to determine clinical benefit of glycaemic control and BP control.
- Retinopathy, nephropathy, and neuropathy are benefited by lowering blood glucose levels with intensive therapy compared to conventional therapy. Also microvascular complication rate decreased by 25%.
- Lowering BP to a mean of 144/82 mmHg significantly reduced strokes, diabetes-related deaths, heart failure, microvascular complications, and visual loss.
66
Summarise the results from the Diabetes Control and Complications Trial (DCCT) about benefits of glycaemic control in T1D
- Lowering blood glucose delayed the onset and slowed the progression of microvascular complications in T1D.
- Improved glycemic control was also associated with reduced cardiovascular events, but the difference was not statistically significant.
- Risks of intensive glucose control = increase in hypoglycaemia.
67
Describe the psychological and social impacts of a diagnosis of diabetes
- Psychological: stressful, depression, overwhelmed, anxiety over loss of control, tired of daily management routine (e.g. finger pricks, medications, carbohydrate counting), nervous about being more vulnerable to illness, learning to adjust constantly, frustrating, routine is inconvenient, fear of hypoglycaemia, focusing on food intake can lead to eating disorders.
- Social: eating out affected (carbohydrate counting), embarrassed about insulin injections in public, regular diabetes appointments may disrupt social/work life, amount of exercise affecting blood glucose levels (impacts on sport participation), restricted, poorer QoL, reduced time spent with family and friends, avoidance of social situations due to fears of hypoglycaemia.
68
Summarise effectiveness of prevention measures for T2D from the Diabetes Prevention Programme Trial
- The most effective intervention for preventing or delaying the onset of T2D is intensive lifestyle modification rather than metformin treatment.
69
Outline the underlying causes of weight gain and it’s increasing prevalence in western society
- Individual: calorie intake in excess of needs, consumption of foods that are high in fat and sugars and highly processed, physical inactivity, working from home (increase in sedentary lifestyle), drinking alcohol/sugary drinks, comfort eating, genetics, medical conditions (hypothyroidism, Cushing’s, depression), medications (steroids, antipsychotics), little sleep, prenatal exposures.
- Socioeconomic: cost of healthy foods, eating out more, poverty, low education, cost of gyms.
- Environmental: changing modes of transport (more accessible and mechanised, so less walking), increasing urbanisation, lack of supportive policies from health sector, areas with little access to fresh produce/healthy food.
70
Outline the social, physical and economic implications of obesity for the individual and the population
- Social: prejudice and discrimination in employments, travel, education and healthcare, fewer friends, lower education, lower employment rates, embarrassed to socialise.
- Physical: increased risk of non-communicable disease (e.g. CVD including MI and stroke, diabetes, OA, cancer, hypertension, sleep apnoea, NAFLD), increased mortality rates.
- Economic: increased costs to NHS for GP appointments, hospital admissions and prescriptions, cost of bariatric surgery, individual time off work due to illness.
71
Identify a strategy to address obesity in the community
- Community exercise programmes e.g. park runs.
- More cycling and walking routes, and safe play areas.
- Fitness tracker/pedometer.
- Supporting healthy food choices.
- Making healthy food affordable.
- Sugar tax on soft drinks containing added sugar.
- Restricting marketing in foods high in sugars, salt and fats.
- Childcare: provide more opportunities for active play and structured physical activity sessions.
- Workplace: promote more active travel to work policies.
- Interventions to improve diet and promote exercise.
- Healthcare professionals discussing weight in appointments.
72
What percentage of adults in UK are overweight or obese?
38% overweight and 26% obese.
73
Give examples of other groups of people other than health professionals that need to be engaged in order to implement strategies in preventing and tackling obesity
- Local authorities.
- Nurseries and childcare facilities.
- Schools (teachers and governors).
- Employers.
74
Describe the relationship between obesity and impaired glucose tolerance
- Intensive lifestyle interventions can reduce the incidence of T2D in people with impaired glucose tolerance.
- Obesity can cause impaired glucose tolerance because the adipose tissue releases mediators which affects beta cells.
75
Outline how pituitary, adrenal and thyroid disease affects individuals psychologically and socially
- Psychiatric: depression (most commonly), mania, anxiety, irritability.
- Hirsutism: body image, self-esteem, social withdrawal, lack of female identity, disrupt interpersonal relationships.
- GH deficiency: difficulties with professional life, social isolation, sexual dysfunction.
76
Outline the physical, psychological and social side effects of chemotherapy
- Physical: hair loss, weakness, fatigue, nausea, infections, SOB (anaemia), bruising, anorexia, memory loss, insomnia.
- Psychological: anxiety and depression, body image (hair loss), stress.
- Social: social isolation (vulnerable), burden to care givers, guilt about survival, impact work and relationships.
77
Outline the steps for a safe and appropriate blood transfusion
- Transfusion should only be used when the benefits outweigh the risks i.e. avoid unnecessary and inappropriate transfusions.
- Gain informed consent from the patient (risks, benefits, alternatives where appropriate). Signed consent not necessary.
- Ensure timely provision of the blood product.
- Check patient’s identity before transfusion.
- Check the correct blood product is being transfused.
- Ensure the patient is ready to start transfusion and there is good venous access.
- Monitor patient during transfusion.
- Document prescription on drug chart.
78
Describe the risks of a blood transfusion
- Patient receiving incorrect blood product (greatest risk).
- Transfusion transmitted infection (extremely low risk).
- Transfusion reaction.
79
What would you do in the event of a blood transfusion reaction?
- Stop transfusion and get senior help.
- Check compatibility of blood component for patient.
- Treat signs and symptoms e.g. antipyretics, antihistamines, fluids.
- Document adverse events in patient notes or report as per trust guidelines if severe reaction (SHOT).
- Send post-transfusion sample to the lab.
80
Outline the organisation of the blood transfusion service in UK
- NHS Blood and Transplant (NHSBT) for England, the Scottish National Blood Transfusion Service (SNBTS), the Welsh Blood Service (WBS) and the Northern Ireland Blood Transfusion Service (NIBTS).
- UK Forum is a body coordinating co-operation between the services.
- Red book of transfusion guidelines concerned with advice and standards, published by the UK Forum’s advisory committee.
- An independent body, the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) advises UK ministers and health departments on the most appropriate ways to ensure the safety of blood, cells, tissues and organs for transfusion/transplantation.
- Each blood service is accountable to health ministers in the relevant UK home country.
- Voluntary blood donations are processed by the authority before being delivered to hospitals and patients.
81
Outline the processes in place after a blood donation is received
- Donations transported by NHSBT vehicles to blood centre where donations are sorted and registered.
- WBC filtered out of each donation.
- Donation then centrifuged to separate out into red cells, platelets and plasma.
- Blood sample from donor also tested to find out blood type and scanned for viruses.
- Once tested, each pack of blood is labelled and stored, ready to be sent to hospitals when requested.
82
How would you manage a patient refusing a blood transfusion?
- Respect the values, beliefs and cultural backgrounds of all patients.
- Anxiety about the risks of transfusion can be reduced by frank and sympathetic discussion with a well-informed clinician.
- Jehovah’s Witnesses decline transfusion of specific blood products, usually whole blood and primary blood components. Individuals vary in their choice and it is important to clearly establish the preference of each patient.
- Advance Decision Documents (Jehovah’s Witnesses) must be respected.
- No one can give consent on behalf of a patient with mental capacity.
- Emergency or critically ill patients with temporary incapacity must be given life-saving transfusion unless there is clear evidence of prior refusal such as a valid Advance Decision Document.
- Where the parents or legal guardians of a child under 16 refuse essential blood transfusion a Specific Issue Order can be rapidly obtained from a court, superseding parental rights.
83
What is the Organ Donation (Deemed Consent) Act 2019?
Unless an individual expressly opts out of organ donation, they are deemed to have given consent.
