S4C1

Question 1

What is a Statement of intent?

Answer 1

a document that allows a medical practitioner to complete a Medical Certificate of Death for a patient in the community who is expected to die.
The GP must have seen the patient within the previous 14 days before death.
If a hospital medical practitioner completes the Statement of Intent for Salford it will be valid until 5pm the next working day.

Question 2

What is a DNA CPR forms?

Answer 2

Do Not Attempt Cardiopulmonary Resuscitation - this policy refers solely to cardiopulmonary resuscitation (CPR) in the event of a cardio respiratory arrest

Question 3

How to assess swallowing?

Answer 3

To check swallowing:

1. Give 3oz water
2. Drink sequentially until all is gone
3. Hand on throat to feel when swallowing
4. Check voice after
5. Is any water sticking?
6. Check for coughing, tickling, voice change

Question 4

Red flags of checking swallowing?

Answer 4

Coughing
Choking
Wet vocal quality
Signs of struggle

Question 5

What cells line the buccal cavity?

What do they produce?

Answer 5

Lined by oral mucosa
thick stratified squamous epithelium that is resistant to abrasion

Produces defensins to inhibit bacterial growth

Question 6

What is Saliva made up of?

Answer 6

99% water
lingual lipases and alpha-amylase
Mucoproteins - act as lubricant
Lysozymes
Immunoglobulins - esp. IgA
Electrolytes
Calcium
Phosphate

Question 7

What controls Saliva secretion?

Answer 7

secreted continuously
salivation is controlled by salivatory nuclei in medulla and pons of the brain stem
Mechanorecptors and chemoreceptors in the mouth stimulate production of saliva with a high water content
Input from higher brain centres and lower GI can induce salivation

Question 8

Describe the Oesophagus

Answer 8

Pharynx to stomach (~25cm)
Normally closed
Highly folded mucosa
Submucosa contains:
        Blood vessels
	Lymphatics 
	Nerves 
	Lymphoid tissue 
	Mucus glands
Lined by stratified squamous epithelium to resist abrasion
Muscularis layer
	Skeletal in first third - voluntary
	Mixed in middle third
	Smooth in last third - involuntary
Outer layer is mostly adventitia
        Fixed to adjacent structures by connective tissue
Last part beyond diaphragm covered with serosa

Question 9

What lining changes are present at the Gastro-oesophageal junction?

Answer 9

changes from squamous to columnar epithelium (glandular)

Question 10

What are the cranial nerve involved in swallowing?

Answer 10

Multiple cranial nerves transmit afferent and efferent control of swallowing.
Nerves V, IX and X provide sensory information
Nerves V, VII, IX, X, XII proved motor innervation to different areas

Question 11

What are the types of dysphagia?

Answer 11

Oropharyngeal
Abnormal bolus transfer to the oesophagus
Difficulty initiating a swallow
Only one manifestation of the primary disease
Oesophageal
Abnormal bolus transport through the oesophagus
Food stops after initiation of swallow
Location of the primary disease

Question 12

Describe the epidemiology of Dysphagia.

Answer 12

Community - 8-16% of older people have symptoms of dysphagia

Old age/ frailty - 33% of >80s have dysphagia

Hospital - Up to 47% of older patients in hospital have dysphagia

Nursing home - 50% in nursing homes have dysphagia, 80% of dementia patients have dysphagia

Question 13

What are the causes of dysphagia?

Answer 13

Neurological
Diseases
Injuries
Abnormalities of CNS, Anterior horn cell, PNS and neuromuscular junction

Physical -Related to head and neck impairments

Respiratory disease - COPD

Psychological

Question 14

Describe Dysphagia after a stroke.

Answer 14

50% of all stroke victims have dysphagia
Usually oropharyngeal
30% increased risk of mortality
Aspiration most important complication
Recovery in majority

Question 15

What is achlasia?

Answer 15

The failure of a ring of muscle fibres, such as a sphincter of the oesophagus, to relax.

Question 16

What are the causes of achalasia?

Answer 16

Associated with HLA-DQw1
Circulating antibodies to enteric neurons suggest that achalasia many be an autoimmune disorder
Potentially result from chronic infections with herpes zoster or measles viruses

Question 17

Describe the epidemiology of Achlasia.

Answer 17

1 per 100,000 per year
Onset before adolescence
Diagnosed between 25-60
Long term risk - 13% 15 year mortality

Question 18

Describe Voluntary passive euthanasia

Answer 18

To allow the patient to die by omission by withdrawing (removing treatment to allow natural progression) or withholding (not performing) treatment

Question 19

Describe Voluntary active euthanasia

Answer 19

A person directly and deliberately causes the patients death

Some people believe this is morally better than passive

Question 20

Describe Non-voluntary euthanasia

Answer 20

The person is unconscious or otherwise unable to make a meaningful choice between living and dying, so an appropriate person takes the decision on their behalf

Question 21

Describe involuntary euthanasia

Answer 21

When the person chooses life but dies anyway

Question 22

What treatments are available for oropharyngeal dysphagia?

Answer 22

Swallowing therapy - SALT
	Swallowing exercises
Dietary changes
	Healthy balanced diet
	Softer foods
	Thickened fluids
	Support at meal times

Feeding tubes
Provides nutrition
Given if at risk of malnutrition and dehydration

Question 23

What are the 2 types of feeding tubes?

Answer 23

Nasogastric tube - passed through nose and down into stomach
Short term
Replaced into other nostril after ~ 1 month

Percutaneous endoscopic gastrostomy (PEG) - directly implanted into your stomach
Long term
Several months before replacing
Major complications are infection and internal bleeding

Question 24

What treatments are available for Oesophageal dysphagia?

Answer 24

Medications - PPIs
Botox - treats achalasia
      6 months
Surgery
      Endoscopic dilation
      Stent insertion

Question 25

What are the 3 integrated phases of swallowing? | Phase - muscle involved - neural control - voluntary control

Answer 25

1. Oral - Striated - Cortex/medulla - Full 2. Pharyngeal - Striated - Medulla - Some 3. Oesophageal - Striated/Smooth - Medulla / ENS - None

Question 26

What is the self-regulation model?

Answer 26

1. Stimuli are presented (i.e., something happens that provokes a reaction, whether that’s a thought, something another person said, getting significant news, etc.) 2. The individual makes sense of the stimuli, cognitively (understanding it) and emotionally (feeling it) 3. The sense-making leads to the individual choosing coping responses (i.e., what the person does to influence their feelings about the stimuli or the actions they take to address the stimuli) 4. The sense-making and coping responses determine the outcomes (i.e., the individual’s overall response and how they choose to behave) 5. The individual evaluates his coping responses in light of these outcomes and determines whether to continue using the same coping responses or alter their formula

Question 27

What are the two main types of oesophageal cancer?

Answer 27

Squamous cell carcinoma (more common in the developing world) typically occurring in the middle and upper thirds of the oesophagus -Strongly associated with smoking and excessive alcohol consumption, as well as chronic achalasia, low vitamin A levels and, rarely, iron deficiency Adenocarcinoma (more common in the developed world) typically occurring in the lower third of the oesophagus - Arises as a consequence of metaplastic epithelium (termed Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant - Risk factors for this subtype are long-standing GORD, obesity, and high dietary fat intake

Question 28

What are the clinical features of oesophageal cancer?

Answer 28

Dysphagia - characteristically progressive -Any patient with dysphagia should be assumed to have cancer until proven otherwise Significant weight loss - due to both dysphagia and cancer-related anorexia

Question 29

What are the red flag symptoms of oesophageal cancer?

Answer 29

``` >55 yrs with weight loss Upper abdominal pain Dyspepsia Reflux Dysphagia ```

Question 30

What is the management of Oesophageal cancer?

Answer 30

70% of patients are treated palliatively as many patients present with advanced disease Surgery - major as both abdo and chest must be opened Stent - help with swallowing Radiotherapy/chemo - reduce tumour size and bleeding Photodynamic therapy - kills nearby cells using light

Question 31

What is Barrett's Oesophagus?

Answer 31

Metaplasia of the oesophageal epithelial lining, whereby normal stratified squamous epithelium are replaced by simple columnar epithelium.

Question 32

What is the pathophysiology of Barrett's?

Answer 32

The vast majority of cases are caused by chronic gastro-oesophageal reflux disease. The epithelium of the oesophagus becomes damaged by the reflux of gastric contents, resulting in a metaplastic transformation. This in turn increases the risk of developing dysplastic and neoplastic changes.

Question 33

What part of the oesophagus is most affected in Barrett's? | What does the endoscopy look like?

Answer 33

The distal oesophagus is most commonly affected. On endoscopy, the oesophagus appears red and velvety, with some preserved pale squamous islands. Diagnosis relies on biopsy demonstrating the presence of simple columnar epithelium within the oesophagus

Question 34

What are the risk factors for Barrett's Oesophagus?

Answer 34

``` Caucasian Male >50 Smoker Obesity Hiatus Hernia Family History ```

Question 35

What are the clinical features for Barrett's Oesophagus?

Answer 35

``` History of GORD Retrosternal chest pain Excessive belching Odynophagia - painful swallowing Chronic cough Hoarseness ```

Question 36

What are the red flag symptoms for malignancy in Barrett's Oesophagus?

Answer 36

``` Dysphagia Weight loss Early satiety - feeling full Malaise Loss of appetite ```

Question 37

How do you manage Barrett's Oesophagus?

Answer 37

Given a proton-pump inhibitor (typically high dose and twice daily). Any medication that affects stomach defences (such as NSAIDs) should be stopped. The patient should be provided with lifestyle advice to reduce the acidic stimulus on the squamous cells (the driver of the metaplastic change.

Question 38

What surrounds the salivary glands?

Answer 38

Surrounded by a Connective tissue capsule with septa that divide the gland into lobules

Question 39

What type is the salivary glands and what do they produce?

Answer 39

Compound tubuloacinar glands - branching duct system Produces serous, mucous or mixed secretions

Question 40

What are the different types of excretory ducts? (from small to big)

Answer 40

Intercalated ducts - small, tiny lumen, simple low cuboidal epithelium Striated ducts - formed by merging intercalated ducts, simple columnar epithelium Intralobular ducts - formed by merging striated ducts, gradually increase in size and become surrounded by CT Interlobular ducts - epithelium may be pseudostratified, may possess cilia, eventually convey saliva into oral cavity

Question 41

What are the major salivary glands and the type of secretion they produce?

Answer 41

Parotid gland - serous Submandibular - seromucous (Mainly serous) Sublingual gland - seromucous (Mainly mucous)