Theme C

Question 1

Criteria for sectioning

Answer 1

3 people must agree:

• You are suffering from a mental disorder
• You need to be detained for assessment and treatment
• It is in the patient’s best interests or protects the safety of patients or others

Question 2

Section 2 Mental health act 1983

Answer 2

Detained in hospital for ASSESSMENT and treatment
Up to 28 days
Can’t renew but can transfer to section 3
Patient CANNOT refuse treatment

Question 3

Section 3 Mental Health Act 1983

Answer 3

Detained in hospital for TREAMENT
Up to 6 months
Can be renewed - 6m-6m-12m
Patient cannot refuse treatment

Question 4

Section 4 Mental Health Act 1983

Answer 4

Emergency situations
Detained for ASSESSMENT
Only needs recommendation of one doctor
Up to 72 hours
Patient can refuse treatment

Question 5

Section 5(2) Mental Health Act 1983

Answer 5

Doctors holding power
Detained from leaving hospital 
Must already be in hospital for treatment 
Up to 72 hours, not renewable
Patients can refuse treatment

Question 6

Section 5(4) Mental Health Act 1983

Answer 6

Nurses holding power
Detained from leaving hospital 
Must already be in hospital for treatment 
Up to 6hours, not renewable
Patients can refuse treatment

Question 7

Human rights that conflict with mental health act

Answer 7

Article 2 - right to life (authorities must make every protection to protect your life, if death under section = coroner’s report)

Article 3 - Prohibition of torture and inhumane or degrading treatment
If patient disagrees with treatment, independent psychiatrist agrees then not breaking article 3. Restraint is not torture unless done other than for protection

Article 5 - right to liberty and security. Limited liberty if section

Right to education - if a child is detained, they must get education

Question 8

Common Law regarding detainment

Answer 8

it is used until the mental health can be put into place

• Right to detain a person if the person is at right to self or others
• Right to restrain with reasonable force (no more than necessary)
• If patient cannot consent: done in best interests
• Treatment must be body recommeded

Question 9

Leventhal’s self-regulatory model of illness behaviour

Answer 9

Representation of a health threat depends on

• Patient interpretation: symptom perception, social messages
• Coping - mechanisms
• Appraisal: is coping effective

These all determine the emotional response to a health threat

Question 10

5 areas of illness representations

Answer 10

• Identity - symptoms, signs, labels and diagnosis
• Cause: perceived causes
• Consequences: perceived physical, social, economical etc
• Timeline: perceived timescale
• Control or cure

Patient may not match the clinician

Question 11

Method of quantifying patient belief on disease

Answer 11

Illness perception questionnaire

Question 12

Coping strategies and groupings

Answer 12

Problem focused - seeking new information, practical support, learning new skills, new interests, actively participating in treatment

Emotion focused: sharing feelings, expressing anger in appropriate ways, acknowledging loss, emotional support

Unhelpful: denial, reoccupation with minor issues, blaming

Question 13

Ways in which patients with learning disabilities are vulnerable

Answer 13

BIOLOGICAL

• Genetic vulnerability
• Brain damage
• Physical disability
• Sensory impairment

SOCIAL

• small circle of friends
• limited opportunities for social interaction
• decreased finance, employment
• decrease support
• at risk of exploitation
• poor housing
• limited choices

PSYCHOLOGICAL

• coping strategies
• low self-esteem
• lack of assertiveness
• feeling helpless

Question 14

Family support available for those with learning difficulties

Answer 14

Access to family advocacy
Family support and info groups
Disability support groups
Skills training and emotional support
Respite care
Formal carers assessment

Question 15

Role of FHx in breast cancer

Answer 15

BRCA gene
Calculate carrier probability using BOADICEA or Manchester scoring system

Refer for screening if

• 1 first degree under 40
• 1 male relative
• 1 first degree with bilateral
• 2 first degree or 3 second degree at any age
• 1 first or second degree with both breast and ovarian

Only do genetic screening if mutation risk 10-20%

Question 16

Preventing cancer in BRCA gene positive women

Answer 16

Risk reducing mastectomy
Risk reducing oophorectomy
Chemoprevention - tamoxifen or raloxifene

Question 17

Impact of caring for a mental health patient

Answer 17

Stress and worry
Social isolation
Guilty for taking time for self
Financial stresses
Physical health problems - demanding role
Depression - feeling hopeless
Frustration and anger - may not have had a choice about being a carer
Low self-esteem
Emotion strain - especially if patient attempts suicide
Patients with mental health are unpredictable and therefore challenging to care for
Stigma from others on behalf of patient - many try to cope alone
Reduced specialist mental health respite

Question 18

Epidemiology of suicide

Answer 18

Increase in men
men choose more lethal methods - hanging, guns
Women tend to choose poisoning and self-cutting
Males have higher success rate

4500 per year
Incidence 19 per 100,000 men and 5 per 100,00 women
Increased in whites and Asians

highest in 15-44 years, although elderly also at risk

RFs
Previous self harm
Single/widow/divorced/separated
Prisoners
Vets/doctors/pharmacists/farmers
Immigrants/refugees
Recent life crisis
Victim of abuse
Mental illness
Chronic physical illness

Question 19

Epidemiology of self harm

Answer 19

Increased in females
1-4% of adults
10% of 15-16 year old girls
Highest in adolescents and college students
Increased in South Asians

RFs
Borderline personality disorder (70% self harm)
MH - depression, bipolar, schizophrenia, drug and alcohol misuse
Domestic violence
Eating disorder
Armed force veterans
Prisoners
Asylum seekers
Victim of abuse
Gay/lesbian/bisexual

Question 20

Members of community mental health team and their roles

Answer 20

Community psychiatric nurse (CPN) - facilitates treatment plan and monitors progress
Social worker - housing and benefits, make the most of available services
Clinical psychologist - delivers CBT
Psychiatrist - diagnoses and develops care plan
OT - maintain own skills and develop new ones. Back to work. Keep up motivation
Pharmacist - advice on meds
Admin staff - first point of call, arrange appointments
Counsellor - taking treatment and developing coping strategies.

Question 21

Barriers to rapid diagnosis and treatment of MI

Answer 21

Symptoms - large variation between patient’s
Patient decision time
- Shorter in men than women (women tend to be atypical)
- STEMI has shorter time as more severe presentation
- ** increase education to decrease time
Symptom recognition - men more likely to realise MI
More likely to use ambulance if
- educated about MI
- Increase symptoms severity
- STEMI
- Increased age
- Increased distance to hospital

• Prehospital ECG, and meds decreases time to treat
• Incorrect level of triage
• Busy EF
• Further from hospital / increases time to treatment
• No access to phone
• Minimal education

Question 22

Outcome indicator

Answer 22

Describes the effects of healthcare on the status of the population e.g. proportion with surgical site infection

Question 23

Process indicator

Answer 23

Measures what is actually done in the giving and receiving of care.
e.g. number of patients receiving the correct antibiotics

Question 24

Advantages of publically available performance indicators

Answer 24

Patient choice
Patient’s want the information
Increased transparency and openness
Managers more likely to focus on quality than cost
Ensures accountability of staff/ providers of care
Identify areas for concern and improvements

Question 25

Disadvantages of publically available performance indicators

Answer 25

Only focussing on measured activity Lose sight of long term outcomes Avoiding new approaches in fear of worse outcome Altering behaviour tot gain advantage - Decreased access to care in high risk patients - e.g. number treatment with antibiotics in first hour will cause overtreatment of non-cases Cost of producing information - resource demanding Patients may not use info

Question 26

Epidemiology of CHD

Answer 26

``` 1/5 men and 1/7 women will die from CHD More common in males Increase South Asians. Increased in northern England Increased with age ``` ``` RFs Smoking Lower socioeconomic group Poor diet - high LDL Alcohol Physical wellbeing: work stress, decreased social support, depression and anxiety Hypertension Diabetes Hypercholesterolaemia FHx - 1st degree relative in men under 55 in women under 65 Obesity ```

Question 27

RFs for CVD from highest to lowest importance

Answer 27

``` Apo-B/Apo-A1 protein (genetic) Current smoker Psychosocial e/g stresses Abdominal obesity Hypertension Daily fruit and veg intake Exercise Diabetes Alcohol ```

Question 28

High risk hypertension patients

Answer 28

Patients at a high risk of complications from hypertension - older age, men over 55, women over 65 - Diabetes - Renal disease/proteinuria - LV hypertrophy - Established vascular disease - CHD - Stroke - Peripheral vascular disease For high risk patients aim for 130/80 Others aim for 140/90

Question 29

Lifestyle changes to reduce CV risk

Answer 29

``` Cardioprotective diet - 5 a day - reduced refined sugars - 2 portions of fish a week - wholegrain carbs Physical activity - 150 minutes of moderate or 75 minutes of high intensity Lose weight Reduce alcohol consumption Smoking cessation Decreased salt consumption ```

Question 30

Health benefits of smoking cessation

Answer 30

``` Decreased lung and other cancers Decreased CVD risk Decreased risk of COPD and respiratory symptoms Decreased risk of infertility Increased life span ``` ``` 20 minutes: decreased HR and BP 12 hours: CO levels drop to normal 2-12 weeks: increase circulation and lung function 1-9 months: decreased cough and SOB 1 year: half risk of CHD 5 years: risk of stroke that of non-smoker 10 years: half risk of lung cancer 15 years: risk of CHD that of non-smoker ```

Question 31

Epidemiology of breast cancer

Answer 31

``` 15% of total cancer paitents 31% of female cancer patients Most common cancer in the UK Increased in women Increases with age Highest in Caucasians - western Europe FHx - BRCA gene defect Most common cause of cancer in 15-49 years Most are detected in stage I or II Incidence has been increasing ``` RFs (separate flashcard)

Question 32

RFs for breast cancer

Answer 32

``` COCP Alcohol Increased adult height Ionising radiation HRT Raised BMI post-menopause (protective pre-menopause) Decreased breast density History of Hodgkin's lymphoma, melanoma, lung, bowel, uterus Ca Increased breast density Benign breast disease Digoxin Diabetes Smoking increased birth weight Increased dietary fat Increased bone mineral density Decreased age at menarche Decreased parity Increased age at menopause Increased age at first giving birth ```

Question 33

Protective factors for breast cancer

Answer 33

``` Breastfeeding Hysterectomy / oophorectomy pre-menopause Physical activity Regular aspirin / NSAIDs Osteoporosis Coeliac disease ```

Question 34

Principles of screening

Answer 34

- Condition should be an important health problem - Recognisable latent or early symptomatic stage - Natural history of condition should be understood - Accepted treatment for patients with recognised disease - Suitable test or examination with high level of accuracy - Test should be acceptable to population - Agreed policy on who to treat - Facilities for diagnosis and treatment should be available - Cost of screening should be balanced - Screening should be a continuing process

Question 35

Define sensitivity

Answer 35

Effectiveness of a test to detect disease in all of those with disease True positives / true positives + false negatives

Question 36

Define specificity

Answer 36

The extent to which a test gives negative results in those without disease True negative / true negatives + false positives

Question 37

Define positive predictive value

Answer 37

Extent in which a person with disease in those that test positive True positive / true positive and false positive

Question 38

Define negative predictive value

Answer 38

Extent to which a person without disease in those with a negative test result True negative / true negative + false negative

Question 39

What needs to be agreed in order for screening program to happen?

Answer 39

``` Frequency of screening Ages at which it should be performed Defined mechanisms for referral and treatment Information systems that can: - Send out invitations - Recall for repeat screening - Follow patients with abnormality - Monitor and evaluate the program ```

Question 40

Breast cancer screening

Answer 40

50-70 (trial extension from 47 to 73) Every 3 years Mammography

Question 41

Benefits of breast cancer screening

Answer 41

Allows for less aggressive treatment Increases prognosis Decreased mortality ``` Pain Radiation Anxiety (false positives) Does not detect 20% of cancers Over diagnosis and over treatment ```

Question 42

Over diagnosis

Answer 42

A cancer or disease that is picked up by screening that would not otherwise have come to attention in that person's lifetime

Question 43

Over treatment

Answer 43

Unnecessary medical interventions - Either due to over diagnosis - OR extensive treatment for a disease which only requires limited treatment.

Question 44

Psychological impact of a cancer diagnosis

Answer 44

Employment and income - financial hardship - may have to give up work due to illness/ appointments Social engagement - harder to participate in social events and maintain friendships - decreased energy and mobility Change in family dynamics Emotional distress Uncertain about unwanted changes to self and life Feelings - shock, disbelief, fear, anxiety, guilt, sadness Depression and anxiety Fertility - can cause infertility Change in relationships with family and friends Inability to perform social roles Changes to sex drive Changes to body image Feelings of guilt and self-blame

Question 45

Factors associated with delayed presentation of breast cancer

Answer 45

``` Older age Lower educational level Non-white ethnicity Non-recognition of symptom seriousness Decreased social support Presentation type - no breast lump No pain Presence of co-existing morbidity Fear of cancer diagnosis Competing life priorities Embarrassment around breast exam ```

Question 46

Effect of culture on psychological response to diagnosis and treatment (breast cancer)

Answer 46

Members of ethnic minorities can often delay in help seeking Blacks and Hispanics have more advanced breast cancer when detected and have poorer survival rates Less likely to have mammogram if single, decreased education and unemployed Increased set backs - unemployment, trouble returning to work, struggle with interpersonal relationships Differences in knowledge and beliefs regarding cause, symptoms, curability and consequences Differences in trust in physicians Some cultures RE male examination worries. Some cultures stress importance towards families and putting others first

Question 47

FHx in breast cancer

Answer 47

BRCA1 and 2 gene Can calculate carrier probability using: BOADICEA or Manchester Scoring system Refer if: - 1 1st degree under 40 - 1 1st degree male - 1 1st degree with bilateral cancer - 3 2nd degree or 2 1st degree with breast cancer at any age - 1 1st or 2nd degree with breast and ovarian cancer

Question 48

Prevention of breast cancer in BRCA +

Answer 48

Risk reducing mastectomy Risk reducing oophorectomy Chemoprevention- tamoxifen or raloxifene

Question 49

Role of a post mortem

Answer 49

Examination of a patient after death | Carried out by a pathologist to establish the cause of death or determine effects of treatment

Question 50

Who is the coroner

Answer 50

Independent official with legal responsibility for the medical-legal investigation of certain deaths including: sudden, unexplained, unnatural or violent in nature

Question 51

What deaths are reportable to the coroner?

Answer 51

Sudden deaths from unknown causes Any case where cause of death unknown Any vehicle, boat, train or plane accident Any suspicious circumstances Suicide If not been seen or treated in last 14 days Any death within 24 hours of admission Due to possible negligence, misconduct or malpractice Any death caused by a treatment or anaesthesia Any infant death or still birth Death due a crime Detained under Mental Health Act 1983 or under police custody Death linked with occupational hazard e.g. mesothelioma, bladder cancer Due to fall or fracture

Question 52

Reasons for retaining tissue after post-mortem

Answer 52

Controlled by Human Tissue Authority - Examined with microscope - Complex abnormality requiring detailed examination - Sample may need preparation prior to examination - Preparation can take weeks

Question 53

Benefits of post mortem

Answer 53

Provides valuable information on cause of death Provides vital info for future treatment/research Gives relatives information which may impact on their health Data can improve and assess medical care and research - cause and prevention of disease Assists in education of doctors and students Provides accurate mortality and morbidity stats to improve public health

Question 54

Confirmation of death

Answer 54

- Full extensive attempts at reversible causes of cardiorespiratory arrest Body temp, endocrine, metabolic and biochemical abnormalities One of the following criteria is met: - Meets criteria for not attempting CPR - Attempts of CPR failed - Life sustaining treatment has been withdrawn Observe individual for minimum 5 minutes Primary care - No mechanical cardiac function: absent central pulse on palpation, absent heart sounds on auscultation Hospital: one of - Asystole on ECG - Absence of pulsatile flow on arterial monitoring - Absence of contractile activity using echo Check reflexes to light, corneal reflexes, and motor response to supra orbital pressure

Question 55

Who can confirm death?

Answer 55

Doctors Nurses Suitably trained ambulance clinicians A doctor's legal duty is to notify the cause of death, not the fact the death has taken place

Question 56

Defining death in primary care

Answer 56

Unresponsive patient with temperature over 35 degrees with no drug or alcohol use - No spontaneous movement - No respiratory effort - No heart sounds or palpable pulse - Absence of corneal reflexes - Pupils fixed and dilated

Question 57

Role of death certificate

Answer 57

Allows relatives to register the death Provides a permanent legal record of death Allows relatives to arrange a funeral and settle estate Provides national statistics regarding cause of death and trends in disease Given to the next of kin to deliver to the Registrar of Births, deaths and marriages within 5 days who decides if it needs reporting to the coroner

Question 58

Reasons that cannot be used as cause of death on death certificate

Answer 58

``` Old age Organ failure e.g. renal/heart/liver Mode of dying e.g. cardiac arrest or shock Diabetes Any abbreviations ```

Question 59

Epidemiology of lung cancer (not RFs)

Answer 59

3rd most common cancer in the UK 2nd most common cancer in males and females in the UK 13% of total cancer cases Increases with age Increased in males Higher in Caucasians FHx - yes 87% non small cell lung cancer 13% small cell lung cancer Most diagnosed in stage 4

Question 60

RFs for lung cancer

Answer 60

``` Smoking Low BMI Past cancer (breast, Hodgkin's lymphoma) Asbestos Radon Silica dust HIV Air pollution Ionising radiation Hx of pneumonia, TB, silicosis, COPD Production of coal/coke Organ transplant recipients Diet high in red meet or total fats ```

Question 61

Medical conditions that decrease the risk of lung cancer

Answer 61

MS Coeliac Parkinson's

Question 62

Role of MDT

Answer 62

Bring together staff with necessary knowledge and skills to ensure high quality diagnosis, treatment and care - Considers patients as whole, not just disease - Takes into account patients views, preferences and circumstances - Makes recommendations not decisions - Final decision is patient and clinician

Question 63

Effective MDT should result in:

Answer 63

- Treatment and care considered by field experts - Offered opportunity to enter clinical trials - Continuity of care - Good communication between 1y, 2y and 3y care - Good data collection - Improved equality - Better adherence to local and national guidelines - Promotion of good working relationships between staff - Optimisation of resources

Question 64

Psychological effects of stoma

Answer 64

``` Shock Depression or anxiety esp if due to prolonged recovery, long lasting disability Alteration in body image - scar Alterations in body function - stoma Change in daily routine Problems with self care and ADLs Impact on relationships Feelings of embarrassment - sex life Rejection from partner Altered sleep habits due to fear or leakage, pain or discomfort Self- conscious Modification of diet Employability and insurance issues ```

Question 65

Physical side effects of chemotherapy

Answer 65

``` Fatigue 2y cancer Weight gain Diabetes Ulcers in mouth Anaemia Memory loss Decreased libido Decreased hair Infertility Neuropathy Osteoporosis Renal, liver, lung, cardiac damage Pain Premature aging Early menopause ```

Question 66

Psychological effects of chemotherapy

Answer 66

``` Fear of recurrence Grief Loss of libido Loss of physical dependence Loss of fertility Depression Body image and self-esteem (hair loss) Relationship strain Worry of outside world (increased infection risk) Decreased energy Anxiety Fear of losing job - missing for illness and medical appointments Requiring assistance with ADLs Emotional stresses Financial stresses - decreased work, cost of travelling Feelings of isolation ```

Question 67

Reducing cardiovascular disease in community

Answer 67

- Policy approaches: global, national and local - Healthcare delivery: access to care, quality of care, drugs and technologies - Heath communication: media - Determinants: cultural and social norms, health inequalities, - Identify groups that are high risk - Assess levels of major preventable causes of CVD Focus on - Education - Schools - Work - Environmental change - Policy change

Question 68

In what ways can education lower CVD?

Answer 68

- Media emphasising importance of lifestyle behaviours and risk factors - Public education campaigns to make aware of guidelines for primary and secondary prevention - Ongoing education of public in CPR - Guide for prevention, diagnosis and treatment made available - Limit food advertising to youth - TV shows for children should promote physical activity - Teaching in schools - Compulsory physical education in schools - healthy school meals - CPR teaching

Question 69

What ways can change in environmental factors lower CVD?

Answer 69

- Supermarkets selling fruit and veg at reasonable price - restaurants offering dishes which meet nutritional guidelines - Low fat/calorie snacks - healthy food at check outs - Support of physical education programmes - Smoke free areas

Question 70

In what ways can a change in policy lower CVD?

Answer 70

- Increase unit price for tobacco - Removal of tobacco advertising - NHS treatment for smoking cessation - 5 a day - 30 mins exercise per day - Change for life - No smoking indoors - Alcohol recommended limits

Question 71

Levels of evidence

Answer 71

1a - meta-analysis of RCTs 1b - evidence from at least one RCT 2a - evidence from at least one well designed controlled study 2b - evidence from at least 1 other type of well designed studies 3 - well designed non-experimental descriptive studies 4 - evidence from expert committee reports or opinions

Question 72

Evidence behind dermatological treatments

Answer 72

High levels of evidence for - PUVA + UVB in psoriasis but is associated with increased cancer risk - Systemic steroids in eczema (no evidence as to which is the best steroid) - Little evidence for methotrexate used in psoriasis - Ciclosporin is the best systemic drug for psoriasis

Question 73

Dangers of excessive sun exposure

Answer 73

Increased risk of skin cancer Skin burn - cells and blood vessels are damaged Heat exhaustion - core temp > 40, sickness, headaches, excessive sweating, feeling faint Heat stroke - core temp > 40, body cells begin to break down and body functions stop working, organ failure Vomiting, confusion, hyperventilation, decreased consciousness Repeated damage leads to premature skin ageing - Decreased elasticity, dry wrinkled and discoloured Damage to eyes

Question 74

UK Mental health services

Answer 74

``` GP Community mental health team (CMHT) Early intervention service (EIS) Crisis resolution team Home based treatment (HBT) Assertive outreach team (AOT) Day hospitals In patient units Improving Access to Psychological therapies (IAPT) Support groups and charities - Mind, Rethink, SANE, AA, The Samaritans ```

Question 75

Role of GP in mental health services

Answer 75

Bulk of treatment done by GP If referral required usually to community mental health team Can refer to early intervention service for psychosis Some patients can present to A&E instead They will be assessed by a psychiatrist and then referred Screen and diagnose MH problems

Question 76

Role of Community Mental Health Team in mental health services

Answer 76

MDT: psychiatrist, mental health social workers, CPNs, psychologists Co-ordinates patient care Monitors patients in the community Initial assessment by psychiatrist then holistic care plan

Question 77

Role of Early Intervention Service in mental health services

Answer 77

Used to improve short and long term outcomes of schizophrenia and other psychotic disorders Exclusively PSYCHOSIS at first presentation - Preventative measures - Earlier detection of untreated cases - Intensive treatment and support in early stages of disease

Question 78

Role of crisis resolution team in mental health services

Answer 78

24/7 Acts as gateway to various psychiatric services e.g. admission Most common referrals comes form GP, A&E and CMHT Rapid assessment to determine if admission of home based therapy (HBT)

Question 79

Role of Home Based Treatment team in mental health services

Answer 79

Short term intensive home based care MDT as per CMHT Visits up to 3x per day with gradual decreased

Question 80

Role of Assertive outreach team in mental health services

Answer 80

For revolving door patients Reluctant to seek help therefore present at times of crisis Often have most complex mental health and social problems Specialist MDT dedicated to engaging them in treatment and providing support.

Question 81

Role of day hospitals or in patient units in mental health services

Answer 81

If they cannot be safely managed in community - Patient is danger to self or others - Requires specialist care or supervised treatment - Patient lacking social structure - Carer can no longer cope / needs respite Most are involuntary / informal

Question 82

Role of key worker in mental health services

Answer 82

Usually a CPN or social worker Co-ordinates and administers treatments Has knowledge of local services and encourages and allows access Liase with GP and other agencies Assists with planning and monitoring of care

Question 83

Specialist mental health services

Answer 83

``` General adult Old age Child and adolescent Liaison Substance abuse Forensic Learning disability ``` Psychiatry

Question 84

Social and cultural factors contributing to depression

Answer 84

Social support - those with more are less likely to get depression - Helps to know they are not alone - Someone pushing them towards getting better Strong family network Decreased socioeconomic group have decreased stability and increased risk of depression High stress job or environment can worsen depression Ethnic minorities are at higher risk of depression - immigration status, decreased income and education level Different populations talk about depression differently and have different help seeking behaviour Services may not be available in native language Less likely to seek help for depression if: elderly, young adult, ethnic minority or decreased social support Financial implications may be barrier to treatment- child care, transport Stigma is different in different populations Different groups have different beliefs and preferences RE treatment e.g. CBT/medication

Question 85

Primary health promotion strategies to increased mental health

Answer 85

- Health visitors for all at risk of post natal depression - School based prevention of violence, bullying, offending or re-offending - Screening and brief interventions for alcohol abuse - Promotion of well being at work - Supported employment for those recovering from mental health problems - CBT for those with medically unexplained symptoms - Suicide prevention - Early intervention service - Debt advice - Anti-stigma campaigns - Increased focus or social support - Tackle social and economic inequalities

Question 86

Political action regarding mental health problems

Answer 86

Public Health White Paper - Tackle substance addiction through minimum alcohol pricing policy - Promote public health interventions to prevent future inequalities - Ensure suicide prevention strategy - Prioritise mental health within smoking cessation - attended to discrimination and stigma around MH (time to change) - Target public mental health interventions for high risk people: cared for children, unemployed and homeless - Promote importance of MH and well being

Question 87

RFs for chronic liver disease

Answer 87

Hepatitis - Travel to high risk areas - IVDU - Male homosexuality - Healthcare worker - Tattoos and piercings - Blood transfusions ``` Alcohol Medications FHx Obesity Metabolic syndromes Heart failure ```

Question 88

Methods for prevention of chronic liver disease

Answer 88

In high risk areas - wash hands, no salad or ice IVDU - needle exchange programmes Condoms PPE at work. Tattoos and piercings only though registered practices National screening of blood transfusions Recommended alcohol limits: 14/ weeks, 2 free days Promote MH to decrease Paracetamol OD Drs aware of drug interactions Obesity: national health eating, change for life. increase exercise programmes In metabolic syndromes: control diabetes and weight

Question 89

Physical problems associated with dialysis

Answer 89

Not treated daily so can feel tired and nauseous between treatments Gain fluid weight between sessions Must limit fluid intake and diet strictly Pain and discomfort Additional for PD: - Increased risk of peritonitis - Problems with sleep and rest

Question 90

Psychosocial issues associated with dialysis

Answer 90

Difficulty arranging transport Difficulty managing a fixed schedule around other plans Difficulties with going on holiday - need treatment while there Alteration in marital, social and family relationships - may develop carer role Feelings of loss of personal control Increased anxiety and depression Uncertain future, large demands of illness Dependence on machinery, medication and healthcare Loss of freedom (less with PD) Feelings of frustration Decreased quality of life Impaired self and body image Impact on sexual activity Feeling like a burden

Question 91

Impact of mental health on primary care

Answer 91

COMMON Large range of conditions seen by GP: adjustment reactions, anxiety, depression, schizophrenia, bipolar disorder, addiction 90% of MH problems are managed by GPs GPs only receive 10% of MH funding 30% of GP visits have a mental health component 30% will have sick leave due to MH problems ``` Patients with MH problems have more consultations regarding physical problems Increased use of services Increased cost Decreased appointments available In 10 minute appointments: - Difficult to spot a problem - Run late if more than 1 problem or brought up last - patient dissatisfied if rushed ```

Question 92

National Framework for Mental Health 1999

Answer 92

Primary care to care for common mental health problems Primary care to contribute to health promotion Lack of clarity regarding management of complex, chronic and disabling non-psychotic problems - GPs require good understanding of healthcare needs in these patients

Question 93

Types of living organ donation

Answer 93

Directed donation Direct altruistic donation Non directed altruistic donation Donor chain

Question 94

Describe a directed organ donation

Answer 94

Living organ donation | Health person donates organ to a specific person where there is a relationship between them

Question 95

Describe a directed altruistic organ donation

Answer 95

Living organ donation | Donation to specific individual but no evidence of genetic or emotional relationship between donor and recipient

Question 96

Describe a non directed altruistic organ donation

Answer 96

Living organ donation | Health person donates organ to unknown recipient matched by NHSBT

Question 97

Describe donor chains in organ donation

Answer 97

Living organ donation Non directed altruistic donors can donate into paired or pooled scheme Match 2+ donors to recipients and the organ at the end of the chain goes to best matched NHSBT patient on list - Occurs when donor can't donate to friend/relative as they are not a match - Enter a pool, when friend gets a kidney, they donate theirs

Question 98

Legislation covering organ donation and tissue removal

Answer 98

Human Tissue Act 2004

Question 99

Human Tissue Act 2004

Answer 99

Covers England, Wales and Northern Ireland Established the Human Tissue Authority to regulate activities concerning removal, storage, use and disposal of human tissue It governs consent for storage and use of organs taken from living person for transplantation Consent for removal is under Mental Capacity Act 2005 All living donors must be approved by HTA before hand

Question 100

Criteria from HTA for living organ donation

Answer 100

- no reward has or is to be given - Consent for organ removal for transplant has been given - Independent assessor has conducted separate interviews with donor and recipient and submitted a report to HTA - Report is sent to HTA approvals team

Question 101

Independent assessor for HTA

Answer 101

- Has completed HTA training - Does not have any connection to those being interviewed - Cannot be the same person who provides info on risk or the procedure - They must assess whether the requirements have been met - will interview donor and recipient separately as well as together and produce a report.

Question 102

When in transplantation does the report not go to the HTA approvals team?

Answer 102

If the donor is a child If the donor is an adult who lacks capacity In all cases of pooled or paired In all altruistic non directed In cases where HTA have not delegated decision making In these cases decision is made by HTA panel

Question 103

What information should living organ donors receive?

Answer 103

1. Surgical procedures and medical treatments, long and short term risks 2. Changes of transplant being successful, side effects and complications 3. Right to withdraw consent at any time - until anaesthetic in live - Until time for first incision in deceased 4. Right to be free of coercion or threat - consent under these circumstances will not be accepted by the independent assessor 5. The fact it is an offence to receive reward or payment and penalties involved - fine and up to 3 years imprisonment 6. Donors can seek expenses - Travel costs and loss of earnings In altruistic non-directed or pooled donors - ANONYMITY of donor and recipient and CONFIDENTIALITY must be respected

Question 104

Rules regarding decreased organ donation

Answer 104

- Removal, storage and use of organs from the deceased is governed by the Human Tissue Act 2004 - Consent must first be obtained - Trained staff should determine if deceased has given consent by checking Organ Donor Register - If consent established, inform those close to decreased - If no records, speakto spouse/partner - done by transplant coordinator - If deceased wishes unknown, but they have nominated representative, they can consent - Ask for consent from relatives - A family member CANNOT OVERRULE deceased wishes - no legal right - Consent is only required from one person in the hierarchy and should be obtained from the highest ranking - If number 1 does not consent, lower down cannot overrule 1. Spouse/partner 2. Parent/child 3. Brother/sister 4. Grandparent/grandchild 5. Niece/nephew 6. step mother/father 7. Half brother/sister 8. Friend If a decision is not made quick enough for organs to not deteriorate, can take minimum steps necessary to preserve organs under HT Act May need coroners consent Use least invasive procedure e.g. cold perfusion

Question 105

Psychosocial impact of diabetes

Answer 105

Travelling: extra stresses - Hot weather can affect insulin - Have to take all insulin supplies with you - Cost of insurance - Risk of hypo in unusual settings Carrying diabetes ID - stigma and labelling Eating out difficult: choosing food with unknown content issues with driving - need to inform DVLA if multiple hypoes - Car insurance CANNOT be increased due to diabetes Restricted career choice - Blanket ban on armed forces - Difficult to manage with shift work - Subject to individual medical assessment in police, ambulance or fire service - Embarrassment of hypo in community or work - Increased sexual dysfunction - Can alter relationship dynamic - Difficulty making new relationships esp if sexual dysfunction - Increased risk in pregnancy - Increased risks to baby Often diagnosed in school - Stigma/bullying - Disruption to schooling with meds - Having to inject at school - Worry of hypos at school - Reliance on teachers for medication - issues with compliance Anxiety/Grief/Depression/Shame/Guilt

Question 106

TB control of spread in the healthcare setting

Answer 106

- Admit to single room until at last 2 weeks of treatment - Minimise the number and duration of outpatient clinics - See patients in less busy areas at less busy times - Risk assess for multi-drug resistance - if it is then negative pressure room only - Don't admit to wards with immunocompromised patietns - Ideally keep at home - Patients wear surgical mask when leaving the room

Question 107

Contact tracing in TB

Answer 107

``` Only screen close contacts Do not routinely trace social contacts Risk assess - Social contacts in high risk groups - School pupils - Hospital in patient in the same bay for > 8 hours - Flights > 8 hours < 3m ago ``` Inform HPA

Question 108

Oppotunistic case finding in TB

Answer 108

Assess new entrants from high burden countries. In places of high TB - mobile Xray e.g. homeless and drug users - can use simple incentives like food and drink Screen prisoners within 48 hours of arrival

Question 109

Methods of ensuring adherence to TB meds

Answer 109

Allocate named TB case manager Health and social care plan and support Offer directly observed therapy if - not adhering - homeless - drug abuse - Multidrug resistant - prison - at patient request - to ill to administer ``` Address fears of stigmatisation Emphasise importance of completing - educate! - Home visits - Education booklet - Random urine tests - Reminder letters - pill counts - Calls/texts as reminders - incentives - Support ```

Question 110

Current stance of the UK on organ donation

Answer 110

Opt - in system | A person has to register their consent to donate organs in the event of their death

Question 111

out-out organ donation system

Answer 111

Presumes consent for organ donation unless a person has registered an objectification in advance. If an objection has not been registered, family can still be given the opportunity to confirm any unregistered objection as an extra safeguard

Question 112

Hard opt put organ donation system | - and countries that use that system

Answer 112

Doctors can remove organs from every adult that dies unless a person has registered to opt out - Austria - Singapore: however, they automatically opt out Muslims

Question 113

Soft opt put organ donation system | - and countries that use that system

Answer 113

Doctors can remove organs from every adult who dies unless they have opted out or relatives tell the doctors not to take organs - Belgium *it is the relatives responsibility to tell the doctors* - Spain: relatives should be consulted

Question 114

Reasons for the opt out system of organ donation

Answer 114

- More organs become available. - better supply of organs - get organs from those who would donate but didn't volunteer - Reduces current pressure on relatives consent when they are grieving. - Up to 90% support organ donation but number signed up is much lower. - Still allows those with strong objections to do so - Reduced wastage of organs - Every organ has the chance to save a life

Question 115

Reasons against the opt out system of organ donation

Answer 115

May not have heard about opt out - may object and still have organs removed (not respecting patients wishes) - Creates a pressure to donate - people may feel ashamed of opting out - Can't dictate what happens to peoples bodies when they die (autonomy) - Very sensitive issue and as such should be entirely voluntary - Costly and complicated to implicate - would need to reach every person - Would be better to design a program to increase number of donors - Suggests that bodies belong to state once dead - seen as offensive - Don't get consent, just a lack of consent.

Question 116

Define audit

Answer 116

Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against the agreed and proven standard for high quality and taking action to bring practice in line with these standards to as to improve the quality of care and health outcomes

Question 117

Main challenges posed to an effective audit

Answer 117

- Purpose: many are done as a tick box exercise with little understanding as to why - Burden of evidence: perceived needs to collect sufficient data from poor sources to justify conclusions - Time: takes a long time to extract meaningful data from notes and written records - Organisational inertia: external pressure on clinicians to measure, report and improve often results in resistance to change - Lack of support: not enough support from superiors and audit departments - Cultural factors: traditional hierarchies can disempower junior doctors

Question 118

Define quality improvement

Answer 118

Wider goal than Audit QI is an umbrella under which audit sits It is used in examining a clinical process and seeking to improve it. There are circumstances where clinical audit may be appropriate - Encourages data collection from a resource that can determine if change is needed - Has a more collaborative working style to investigate problems

Question 119

Problems with audits

Answer 119

Not useful if there are no national agreed criteria and standards e.g. patient safety, patient experience and performance of a service Rarely take into account local differences

Question 120

When should an audit be used?

Answer 120

Used to check clinical care meets defined quality standards and monitor improvements to address shortfalls identified Most effective for ensuring compliance with specific clinical standards and driving clinical care improvement

Question 121

Pre-requisites for an audit

Answer 121

Evidence based clinical standards drawn from best practice | Audit proforma comprised of measures derived from the standards

Question 122

PDSA cycle

Answer 122

Plan Do Study Act Used to introduce and test potential quality improvements and refine them on a small scale prior to wholesale implementation Most effective when a procedure, process or system needs changing or a new procedure, process of system needs introducing Tests changes to assess their impact, ensuring new ideas improve quality before implementation on a wider scale Making changes can give unexpected results so it is safer to test on a small scale first and allows stakeholders to be involved in proposed changes.

Question 123

Risk factors for drug addiction

Answer 123

``` Early aggressive behaviour Lack of parental supervision Substance abuse Drug availability Poverty Care giver who uses drugs Fhx of drug addiction Male Mental health disorder Peer pressure Loneliness, anxiety or depression Child abuse Neglect Poor academic performance ADHD Bullying Deviant peer group Conduct disorder Poor family relationships ```

Question 124

Protective factors against drug addiction

Answer 124

``` Self-control Parental monitoring Academic competence Anti-drug use policies Strong neighbourhood attachment Consistent discipline in childhood ```

Question 125

Aetiology of drug addiction

Answer 125

Environmental - risk factors Genetics: development of addiction can be influenced by genetics

Question 126

Stages of drug addiction

Answer 126

Initial use - Motivated by: curiosity, peer pressure, psychodynamic processes - If drug taken repeatedly - casual drug use - More frequently using high doses - intensive drug use - Compulsive drug use = substance has strong motivational properties and appears to govern an individuals behaviour 1. Experimental or circumstantial 2. Casual drug use 3. Intensive drug use 4. Compulsive drug use 5. Addiction

Question 127

Theories of drug addiction

Answer 127

Physical dependency model - after repeated exposure, get withdrawal symptoms. They act as negative reinforcement and cause continued drug use Positive reinforcement model - drug acts a positive reinforce causing a change in behaviour Reinforcement system in the brain - Reinforcers are thought to increase the effect of dopamine - Increased dopamine release

Question 128

Potential future health promotion strategies for alcohol reduction

Answer 128

Minimum unit pricing Label alcohol with health warnings Sale of alcohol in shops restricted to certain times Higher tax on alcohol Prohibit alcohol advertising and sponsorship - or limit to purely factual information Regulartion of alcohol packaging and design Train all health and social workers on giving alcohol advice

Question 129

Recommended alcohol units

Answer 129

No more than 14 units per week in men and women | Ideally 2 alcohol free days

Question 130

Stages of change

Answer 130

``` Precontemplation Contemplation Preparation Action Maintenance Relapse ```

Question 131

Stages of change | Precontemplation stage

Answer 131

User is not considering change Is aware of negative consequences Is unlikely to take action soon - Need information linking substance with problems - Brief intervention: education about negative consequences Interview approach - express concern - agree to disagree about severity of problem - suggest bringing family member - explore perception of drug abuse problem

Question 132

Stages of change | Contemplation stage

Answer 132

User is aware of some pros and cons but feels ambivalent to change - not yet committed to a change - Explore feelings of ambivalence - Seek to increase awareness of continued abuse and benefits of stopping Interview approach - Elicit positives and negatives, help tip the decisional balance - Ask about past abstinence - Consider trial - Self-Motivational statements of intent and commitment

Question 133

Stages of change | Preparation

Answer 133

User has decided to change and begins to plan steps towards recovery - Needs to work on strengthening commitment - List options for treatment to choose from Interview approach - Clarify goals and strategies - Acknowledge significance, offer options and advice - help patient decide on achievable action - Consider and lower barriers for change - finances, transport - Have them publically announce plans for change

Question 134

Stages of change | Action

Answer 134

User tries new behaviours, not yet stable First active step towards change - help executing the plan - brief interventions can help prevent relapse Interview approach - Source of encouragement and support - Acknowledge negatives and reinforce importance in continuing - Support realistic view of change using small steps - Identify high risk situations and develop coping strategies

Question 135

Stages of change | Maintenance

Answer 135

Established new behaviours on a long term basis - help with relapse prevention - Support lifestyle changes - Help to practice and use coping strategies - Maintain supportive contact - Anticipate difficulties and recognise the struggle

Question 136

Stages of change | Relapse

Answer 136

recurrence of symptoms and must now cope with consequence and decide what to do next - Help them re-enter the change cycle - Commend any willingness to reconsider positive change - Explore what can be learned from relapse - Express concern about relapse - Support patient so recovery seems achievable

Question 137

Limitations and harms of PSA as screening tool

Answer 137

- may not reduce the change of dying from prostate cancer. Some tumours grow very slowly and are unlikely to threaten life. OVERDIAGNOSIS AND OVERTREATMENT - Side effects of overtreatment: surgery, radiotherapy (urinary incontinence, bowel control issues, ED, infection) - May not be useful for those with fast growing as may have mets before detection - False positives and false negatives (anxiety) - Most men with raised PSA do not have prostate cancer - Non specific test as will detect aggressive and slow growing tumours

Question 138

When is PSA useful

Answer 138

For monitoring for recurrence

Question 139

When should a PSA be done

Answer 139

If prostate cancer is suspected ``` A man over 50 can ask for PSA - GP must explain risks and benefits - Give any written info - Answer any questions - ```

Question 140

When should a PSA not be done

Answer 140

Recent urine infection Ejaculated in last 48 hours Exercised heavily in last 48 hours Had a prostate biopsy in the last 6 weeks

Question 141

Lung disease associated with asbestosis exposure & associated professions

Answer 141

Mesothelioma Asbestosis Construction workers Home remodellers Shipyard workers Workers who mine, mill or manufacture it

Question 142

Lung disease associated with silica exposure & associated professions

Answer 142

Silicosis ``` Coal miners Foundry works Potters Sand blasters Tunnel workers ```

Question 143

Jobs associated with asthma

Answer 143

Woodworkers - wood dust Pain sprayer - isocyanates Solderer - colophony

Question 144

Epidemiology of depression

Answer 144

``` 25% at some point 5% annual 1/4 women, 1/10 men More common in women Increased in Blacks, Asians, refugees Increased in 25-44 and elderly ``` RFs - Unemployment - Lower income - Debt - Violence - Stressful life events - Inadequate housing - Poverty - Smoking - Lower education - Genetic FHx - Pregnancy (post natal) - Physical illness causing pain - Dementia - Other mental health problems

Question 145

Associations and issues between mental health problems and sensory impairments

Answer 145

- May have unassessed or undiagnosed LD as verbal IQ tests are inaccurate - Few residential or nursing homes can sign to dead people - Limited access to specialist mental health services - postcode lottery - Difficulties communicating with GPs - Equal prevalence of mental health problems In children higher prevalence due to: - Excess organic problems - Excess emotional, physiological and behavioural disorders - Delays to access which increases duration - Care often poor - Increased stresses - Socially isolated Lack or understanding Little support available

Question 146

Methods of preventing AKI

Answer 146

NEWS score to assess those at risk iodinated contrast agents - IV volume expansion if high risk or acute illness with sodium chloride Stop ACEi and ARBs if GFR < 40 Advice from pharmacy if high risk

Question 147

Detection of AKI

Answer 147

RIFLE, AKIN, KDIGO Rise of creatinine of greater than 26 in 48 hours 50% rise in creatinine within 7 days Fall in urine output to less than 0.5ml/kg/hr

Question 148

Risk factors for AKI

Answer 148

``` Over 65 Heart failure Liver disease CKD Past AKI Diabetes Fluid intake dependent on carer Hypovolaemia Oliguria Haematological malignancy Sepsis Urological obstruction Iodinated contrast agents Nephrotoxic meds: ACEi, ARBs, NSAIDs, aminoglycosides, diuretics Deteriorating NEWS score ```

Question 149

Define addiction

Answer 149

Compulsive need to use a habit forming substance | This compulsion is accompanied by an increased tolerance and experience of withdrawal symptoms

Question 150

Impact of addiction on health

Answer 150

``` Organ damage Hormone imbalance Cancer Prenatal and fertility issues GI disease HIV/AIDS/hepatitis Depression Anxiety Memory loss Mood swings Paranoia ```

Question 151

Impacts of addiction on society

Answer 151

More work days lost Increased number of people claiming benefits and not paying taxes Increased criminal activity Illegal drugs - funding other types of criminality Drain on healthcare resources Drain on economy High risk of accidents or becoming a victim of crime Can destroy communities

Question 152

Impacts of addiction on the family

Answer 152

``` Addict is hard to live with Increased physical and verbal abuse Behaviour is erratic Some can be high functioning but most are poor providers Financial difficulties Unable to care for children - neglect Set bad examples to child May steal or manipulate family members Increased divorce rate Change of relationship with friends and family ```

Question 153

Impacts of addiction on the individual

Answer 153

``` Person is obsessed with substance and neglects other areas of their lives Life is unfulfilling - filled with despair Increased morbidity Increased mortality Worse mental health Increased suicide risk Poor attendance at work Mood swings Hard to find employment Increased probation, arrests, prison time Increased homelessness Secretive behaviour ```

Question 154

Information that should be given to an obese person

Answer 154

Being overweight and general health risks Realistic targets for weight loss Distinguishing between weight loss and maintaining weight loss Realistic exercise and healthier eating targets Treatment options Healthy eating in general Medical and surgical options

Question 155

Diet changes advised for obese person

Answer 155

DO NOT - use restrictive and nutritionally unbalanced diets as they are ineffective in the long term and can be harmful - FOLLOW FADS BE - Flexible - Encourage diet improvement even if no weight loss Diet with 600kcal deficit per day Can consider 800-1600 kcal per day but less balanced Swap unhealthy and high energy foods for healthier choices 5 fruit and veg a day Wholegrain varieties of starches Lower sugar milk and dairy - yoghurt, soy Eat beans, pulses, fish, eggs, meat and other protein 2 portions of fish per week Plenty of fluid

Question 156

Define overweight, obese and morbidly obese

Answer 156

Over weight BMI >25 Obese BMI > 30 Morbidly obese BMI > 40

Question 157

Social implications of obesity

Answer 157

``` Discrimination Lower wages Lower quality of life Transport difficulties - planes, trains, buses Difficulty buying clothes More likely to commit suicide More likely to divorce Fewer friends Depression and anxiety Body dissatisfaction ```

Question 158

Physical implications of obesity

Answer 158

``` Increased risk of: heart disease stroke diabetes hypertension high cholesterol asthma sleep apnoea gallstones kidney stones infertility OA fatty liver disease cancer: leukaemia, breast, colon Increased morbidity and mortality life expectancy reduced by more than 9 years ```

Question 159

Economic implications of obesity

Answer 159

``` Lost days of work High employer insurance premiums Lower wages and income Large costs on the health care systems Increased social services having to provide care ```

Question 160

Members of the cancer MDT

Answer 160

``` Surgeon Radiologist Histopathologist Oncologist - clinical and medical Haematologist Palliative care specialist GP Physicians of appropriate speciality Clinical nurse specialist Ward nurses MDT coordinator Admin/managerial ```

Question 161

Domains important for MDT functioning

Answer 161

Structure - Membership and attendance - Technology (Availability and use) - Physical environment of the meeting room - Preparation for MDTs - Organisation and admin during the meeting Clinical decision making - Team working - patient centred care Team governance - Leadership - Data collection, analysis and audit Professional development and education of team members

Question 162

Benefits of an MDT

Answer 162

Improved clinical decision making More coordinated patient care Improvement to overall quality of care Evidence based treatment decisions Increased number of patients being considered for trials Improved timeliness of tests and treatments Improved survival rates Increase proportion of patients staged (cancer)

Question 163

Epidemiology of obesity

Answer 163

62% of UK adults are overweight or obese 65% men, 58% women 25% of them are obese prevalence is similar among men and women More men are overweight More women are obese Women are more likely to have extremely high BMI values

Question 164

Causes of obesity - contributing factors

Answer 164

May behavioural, societal and physiological factors Outlined in Foresight Report 2007 BIOLOGY - influence of genetics and ill health: Prader-Willi, hypothyroidism, Cushing's ACTIVITY ENVIRONMENT - influence of environment on the individuals activity behaviour - e.g. decision to cycle to work influenced by road safety, cycle shelters, showers PHYSICAL ACTIVITY - Type, frequency, intensity SOCIETAL INFLUENCES - Impact of media, education, peer pressure, culture INDIVIDUAL PSYCHOLOGY - Drive for particular foods - Consumption patterns - Physical activity patterns or preferences FOOD ENVIRONMENT - Availability and quality of fruit and veg near home - Demand for convenience - Lack of perceived time FOOD CONSUMPTION - tendency to graze - Parental control

Question 165

Reasons for increasing obesity prevalence

Answer 165

``` Frequent large meals Good high in refined grains, red meat, unhealthy fats, sugary drinks Increased television Increased use of cars Busier lifestyles Longer commutes - snacking Increased advertising Sleep issues Increased stresses and boredom Decreased cost of fats and sugars ```

Question 166

What is the HPA

Answer 166

Health Protection Agency | Key organisation in the control of communicable diseases

Question 167

What law covers control of infectious diseases?

Answer 167

Public Health Act 1984 (control of diseases) & 1988 (infectious diseases) Aims to reduce the spread of communicable disease - Act on clinical suspicions, do not wait for definitive diagnosis - Legal requirement to notify HPA - Notify Consultant in Communicable Disease Control

Question 168

Ways to minimise infection spread?

Answer 168

Treat patient Minimise chances of other getting same infection - Chemoprophylaxis after meningitis to contacts Reduce infectiousness of the bug = antibiotics Contain infectivity - Isolate in side room - Exclusion from certain activities e.g. work or school - Hand washing - PPE - Managing blood and body fluids adequately - Education of patients - Cough etiquette IMMUNISATION

Question 169

Powers of the consultant in communicable disease control

Answer 169

``` Notification of infectious disease Prevents sale of infected articles Prevents infected people from using public transport cleaning and disinfection of premises Excluding people from work and school Offering immunisation Compulsory exclusion Remove to hospital and detain there Obtaining information from households and schools to prevent spread of disease ```

Question 170

Notifiable disease list

Answer 170

``` Polio Acute encephalitis Anthrax Cholera Diphtheria Dysentery FOOD POISONING Malaria MEASLES MENINGIGT MUMPS Plague Rabies RUBELLA SCARLET FEVER SMALL POX TETANUS TB typhoid fever VIRAL HEPATITS viral haemorrhagic fever WHOOPING COUGH YELLOW FEVER ``` **HIV is not a notifiable disease but practioners should make sure that any sexual partners have been notified

Question 171

Define primary prevention

Answer 171

Activities aimed at stopping a disease from developing in the first place

Question 172

Define secondary prevention

Answer 172

Activities aimed at stopping adverse events once a disease has happened

Question 173

Define tertiary prevention

Answer 173

Limiting the impact that adverse effects have on health

Question 174

Primary, secondary and tertiary prevention examples in CHD

Answer 174

Primary - Smoking cessation in someone without heart disease - Weight loss in someone without heart disease or diabetes Secondary - Antiplatelet therapy post MI - Statins for those post MI or stroke Tertiary - Beta blockers in heart failure - Cardiac rehabilitation program post MI

Question 175

What is the prevention paradox?

Answer 175

A preventative measure that brings a large benefit to the community offers little to each participating individual Most heart disease occurs in people who are not high risk. It is easy to identify those at high risk If you improve chances for people at low risk then stands to gain more as a population.

Question 176

Define risk

Answer 176

Probability that an even occurs in a given time

Question 177

Determining risk of CHD

Answer 177

Joint British Societies Risk Prediction chart Uses UK GP data rather than Framingham data QRISK 2 - Overestimates low risk - Underestimates high risk - Does not take into account socioeconomic position and ethnicity

Question 178

QRISK2 criteria

Answer 178

``` Age Sex Postcode Smoking Diabetes Angina or MI in first degree relative < 60 CKD stage 4 or 5 AF On BP treatment RA Cholesterol BMI ```

Question 179

Diabetes Prevention Program Trial

Answer 179

DPPT In overweight people with raised fasting glucose - Allocated to either: intensive lifestyle changes OR standard lifestyle recommendations + metformin OR placebo - Incidence of diabetes was lower in the intensive lifestyle changes group - Lifestyle is better than metformin for preventing T2DM Intensive lifestyle was minimum 150 minutes of exercise + 16 lesson curriculum + 7% weight loss

Question 180

Risk factors for T2DM with relation to weight

Answer 180

Degree in which patient is overweight Change in weight Duration patient is overweight Increasing BMI

Question 181

Basic CAMHS structure

Answer 181

``` Informal Tier Tier 1 Tier 2 Tier 3 Tier 4 ```

Question 182

CAMHS Tier 1

Answer 182

Professionals Any tier 1 person can refer to a PRIMARY MENTAL HEALTH WORKER They are not mental health specialists but have regular contact with children and young people Offer advice and treatment for less severe problems, promote good mental health, facilitate early identification of problems and refer - Teaching assistants - Teachers - Paediatricians - GP - Social worker - Health visitor - School worker - Public health nurses - Voluntary workers

Question 183

Role of primary mental health worker

Answer 183

In CAMHS Bridge between tier 1 and 2 - provides consultation and advice to the professional in tier 1 - Assess the child - Carry out short term work with the family - up to 4 session - Co work with referring professions - Refer onto other agencies .e.g. social service and education and support services - Refer up tiers 2, 3, 4

Question 184

CAMHS Tier 2

Answer 184

Everyone that specialises in child mental health Specialist CAMHS clinicians working in community setting Offer consultations to support severe or complex needs - Psychologist - Nurse - OT - Social worker - Psychiatrist - Psychologist - CPNs - Creative therapists

Question 185

CAMHS Tier 3

Answer 185

Teams depend on locality and requirements Very specialist teams ``` Family therapy LD Attention problems Looked after children Eating disorder Autism Adoption support Paediatric liaison Self-harm Psychosis Bereavement Palliative care ```

Question 186

CAMHS Tier 4

Answer 186

``` Inpatient units For young people with - psychosis - severe eating disorders - severe OCD - severe depression ```

Question 187

What are health visitors

Answer 187

Qualified nurses with specialist training who work in the community

Question 188

Steps of an audit

Answer 188

1. Select topic 2. Review literature 3. Set standards 4. Design audit 5. Collect data 6. Analyse data 7. Feedback findings 8. Change practice 9. Set/review standards 10. Reaudit

Question 189

Steps of an audit | Select a topic

Answer 189

Can be a - Process e.g. timing and content of letters, - Structure e.g. quality of facilities - Outcome e.g. number of people referred Topic should encompass as many as possible of: - Concern to service users - Important and of interest to members of the team - Of clinical concern - Financially important - local or national importance - Practically viable - New research evidence available on the topic - Ideally supported by good research

Question 190

Steps of an audit | Review literature

Answer 190

Find out if there are any national standards to base your standards on Find out if any previous audits have been carried out to help with the designing methods and setting standards Look for guidelines or research on the topic

Question 191

Steps of an audit | Set standards

Answer 191

Requires discussion between staff and the reading of relevant literature Comparing current practice against standards can highlight problems which may have otherwise been unrecognised Choose a criterion and a target (% to be achieved) A criterion should be clear and precise, should be measureable and indicates the boundaries of measurement

Question 192

Steps of an audit | Design an audit

Answer 192

``` Who will be inolveed What data needs collecting Sample size Data analysis Start and end date ```

Question 193

Steps of an audit | Data collection

Answer 193

Design should have already been determined Maintain confidentiality using patient idetifiers with separate lists Develop a way of storing data - coding system make sure it is secure and conforms to legal requirements

Question 194

Steps of an audit | Feedback findings

Answer 194

Communicate findings to relevant stakeholders if the audit is to have any impact on quality of service being provided - Audit reports (passive) - Discussion of results (active)

Question 195

Steps of an audit | Change practice

Answer 195

If care needs improving - create action plan - What needs to change - How can that be achieved - Who needs to take these actions - When will they happen - How will they be monitored - How and when to assess

Question 196

Define relative risk

Answer 196

Also referred to as risk ratio It is the probability of an event occurring e.g. developing a disease in an exposed group vs non exposed group RR = probability when exposed / probability when not exposed Used in RCTs and cohorts

Question 197

Define absolute risk

Answer 197

Risk of developing the disease over a period of time Number of events in a group/ number of people within the group

Question 198

Define relative risk reduction

Answer 198

Absolute risk in control - (absolute risk in treatment / absolute risk in control) RRR = 1 - relative risk

Question 199

Define absolute risk reduction

Answer 199

Absolute risk in the control group - absolute risk in the treatment group

Question 200

Number needed to treat

Answer 200

1 / absolute risk reduction Needs to be expressed as a whole number NNT BENEFIT = round up NNT HARM = round down Extending the time period in which the risk is expressed will decrease the number needed to treat

Question 201

What information is needed in order to assess a number needed to treat?

Answer 201

Needs to have a time period e.g. within 10 years Look at the nature of the outcome Decide if looking at something that is getting better or work (NNT benefit or harm)

Question 202

Define attributable risk

Answer 202

Differnece in the rate of a condition between an exposed and unexposed population. Also called risk difference of risk rate difference. Incidence in exposed - incidence in unexposed

Question 203

Define population attributable risk

Answer 203

Reduction in incidence that would be observed if the population were entirely unexposed in comparison to its current exposure pattern.

Question 204

Strategies to tackle obesity in the community

Answer 204

Increase availability of heathier food in public service venues Improve availability of healthy food - subsidise Provide incentives for food retailers to locate healthier products in prime areas Small portion sizes in public service venues Limit advertisement of unhealthy goods Discourage consumption of sweet drinks Increase support for breastfeeding Increase school PE requirements Compulsory PE Enhance infrastructure to encourage walking and cycling Improve safety in areas where people could be physically active e.g. schools Healthy school dinners Clear food labelling Increased education - change for life Weight loss advice Promote physical activity in the work place Raise awareness of complications Teaching in schools about healthy diets and exercise

Question 205

National cancer research institute

Answer 205

Started in 2000 with NHS cancer plan Brings together all the key players in research to identify where research is most needed Partnership of UK cancer research funders to promote collaboration Support advancement of areas lacking in research NHS supported clinical trials Comprised of 7 government partners and 14 charities

Question 206

Activities of the national cancer research institute

Answer 206

Maintains database of cancer research in UK Organising annual NCRI cancer conference Developing a plan to network UK cancer registries and encourage epidemiological research Revitalise UK radiotherapy research Development of the national Cancer Research Network Setting up a network of experimental cancer medicine centres Publish reports on key areas Establish the National Cancer Intelligence Network

Question 207

National Cancer Research Institute AIMS

Answer 207

Foster research aimed at: - better prevention leading to lower cancer risk for the individual - earlier diagnosis - better, cost effective treatments with more people cured - less inequality in outcomes for patients - improvements in health and quality of life for people who survive cancer

Question 208

National Cancer Research Network

Answer 208

Aims to improve speed, quality and integration of research to improve patient care - Increase funding for trials - Provides researchers with practical support - Increases participation in clinical research, raising the number of patients entering trials - Engages with stakeholders - Ensures research is translated into benefits for patients,

Question 209

Define screening

Answer 209

Public health service Members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or complications, are asked a question or offered a test to see who are more likely to be helped than harmed by further tests of treatment to reduce the risk of disease or its complications

Question 210

Screening programs offered in the UK

Answer 210

``` Retinography for diabetic eye disease breast cancer mammography Colorectal cancer FOB Cervical cancer - smear AAA - US Down's syndrome Guthrie Heel Prick test - PKU, hypothyroidism DDH - infant screening Deafness - neonatal screening ```

Question 211

Diabetic retinopathy screening

Answer 211

Everyone over 12 with diabetes receives it annually | During pregnancy - at first antenatal clinic and at 28 weeks

Question 212

Breast cancer screening

Answer 212

Mammography Women aged 50-70 (47-73) Every 3 years

Question 213

Colorectal cancer screening

Answer 213

Faecal occult blood | Every 2 years from 60-74

Question 214

Cervical screening

Answer 214

Cervical Smear Every 3 years from 25-50, every 5 years 50-65 Tests for HPV and cell changes

Question 215

AAA screening

Answer 215

Men aged 65 are offered US scan If normal, never tested again If small-medium then regular monitoring

Question 216

Key concepts of screening

Answer 216

Requires a judgement between balance of helping and harming Early detection is necessary for screening but in itself does not provide benefit Population screening is about programmes not tests

Question 217

Harms of screening

Answer 217

AAA - a person that dies during surgical repair of AAA detected through screening Down's - loss of normal foetal following investigation of a high risk screening test Colorectal cancer - healthy individual who suffers from perforation of bowel during colonoscopy following screening Patients receiving additional tests due to false positives on screening e.g. biopsy

Question 218

Lead time bias

Answer 218

If you succeed in early detection of a disease then you increase the time between diagnosis and death - even if treatment is useless - care not to count this extra time as benefit - Need to use number of events prevented rather than survival time.

Question 219

Healthy screenee effect

Answer 219

Patients who participate in screening often make other health conscious choices Different lifestyles between those who take up screening and those who don't

Question 220

Length bias

Answer 220

Screening tends to detect disease which progresses more slowly The screening detected disease will have better outcomes as they have less aggressive disease It appears as if the cancers detected by screening have better outcome

Question 221

Mental Capacity Act 2005

Answer 221

Provides statutory framework to empower vulnerable people who are not able to make their own decisions. It makes it clear who can make decisions, in which situations and how they should go about this. It applies to those aged 16 and over.

Question 222

Principles of the Mental Capacity Act 2005

Answer 222

1. Presumption of capacity Every adult has the right to make their own decisions and must be presumed to have capacity unless proved otherwise 2. The right for individuals to be supported to make their decisions People must be given all appropriate help before anyone concludes they cannot make decisions 3. Individuals retain the right to make an unwise decision 4. Best interests anything done for or on behalf of people without capacity must be in their best interests 5. Least restrictive intervention possible Assessment of mental capacity is specific for each individual decision at any given time

Question 223

To have capacity a person must:

Answer 223

Be able to understand information provided Be able to retain this information Be able to weigh up pros and cons Be able to express this decision

Question 224

When can restraint be used in those that lack capacity

Answer 224

Restraint is only permitted if it is deemed reasonable to prevent harm Needs to be proportionate to likelihood and seriousness of harm

Question 225

Advanced Care Planning

Answer 225

Gives the person the right to make decisions about healthcare treatment in the future for times when they no longer have capacity. - Replaced advanced directives - Only over 18s - Must currently have capacity - Any treatment can be refused except for those to keep a person comfortable - food, water, warmth, shelter - Can express which treatments you would like but cannot demand - It carries the same weight as a person with capacity so best interests does not apply - Can be verbal unless about life-sustaining treatment which must be written and signed by patient and a witness, plus a statement that it is still to apply if life is at risk - Becomes invalid if the decision is withdrawn while still has capacity - Must apply to the specific circumstance in question

Question 226

Lasting powers of attorney

Answer 226

Can appoint an attorney to act on their behalf if they lose capacity in the future Lets them make financial, property, health and welfare decisions Attorney must be over 18 Only comes into force once a person loses capacity Must be registered with the Office of Public Guardian

Question 227

Independent Mental Capacity Advocate

Answer 227

Appointed if someone without capacity has no one to speak for them Makes representations about patients wishes Can challenge the decision maker MUST be involved if: - Serious medical treatment - Stay of more than 28 days in hospital or 8 weeks in care home - Change to accommodation

Question 228

Deprivation of liberty safeguards

Answer 228

Provides legal protection for vulnerable adults who are not detained under Mental Health Act 1983 but are restricted in freedom due to an inability ot consent to care or accept treatment Anyone over 18 with - mental disorder or disability of the mind e.g. dementia or profound LD - Lack of capacity to give informed consent If a person lacks capacity, must apply to a supervisory body for authorisation of deprivation of liberty

Question 229

NHS Outcomes Framework

Answer 229

Provides a national overview of NHS performance Supports the secretary of state in holding NHS England to account for improving outcomes and acts to aim to encourage a change in health inequalities. 5 domains - Preventing people dying prematurely - Enhancing quality of life for people with long term conditions - Helping people to recover from periods of ill health or following injury - Ensuring people have a positive experience of care - Treating and caring for people in a safe environment and protecting them from avoidable harms

Question 230

Measuring quality of cancer services

Answer 230

NHS Outcomes framework - One year survival from all cancers - 5 year survival from all cancers - One year survival from breast, lung, colorectal cancers - 5 year survival from breast, lung, colorectal cancers - 5 year survival from all cancers in children Cancer Patient Experience Survey CCG Outcomes Indicator Set PROMs

Question 231

CCG Outcomes Indicator Set for monitor quality of health services - CANCER

Answer 231

Drives local improvement and sets priorities - Under 75 mortality from cancer - 1 and 5 year survival from all cancers - Record of stage of cancer at diagnosis - Percentage of cancers detected at stage 1 and 2 - Mortality from breast cancer in females - Patient experience and survivorship

Question 232

Cancer Patient Experience Survey

Answer 232

CPES National assessment of patient satisfaction with their cancer treatment. In 2014 - asked 110,000 patients, 64% response Positives - Given enough information - Offered a range of treatment options - Treated with respect and dignity Negatives - GP and nurses in GP could do more - Not enough care form health and social services post discharge

Question 233

Cancer registries

Answer 233

- 4 in the UK - Responsible for registering all cancer that occur in their population - Prime aim to establish incidence and survival - Identify all new cases and follow them through to death - Allows comparison of incidence in different regions - Allows researchers to examine long term outcome provides inform on cancer epidemiology

Question 234

Bradford Hill Criteria

Answer 234

Criteria for causation - minimal conditions necessary to provide adequate evidence of a causal relationship between incidence and possible consequence 1. Strength - larger = more likely to be causal 2. Consistency (reproducibility) 3. Specificity - causation likely if a very specific population and disease with no other likely explanation 4. Temporality - effect after cause 5. Biological gradient - greater exposure = greater incidence of effect 6. Plausibility 7. Coherence - between epidemiological findings and lab findings 8. Experiment 9. Analogy

Question 235

Risk factors for chronic liver disease

Answer 235

``` Alcohol Obesity Viral hepatitis metabolic syndrome healthcare workers IVDU Unprotected sex with multiple partners Working with toxic chemicals Certain medications ```

Question 236

Ways to restrict alcohol consumption

Answer 236

``` Minimum unit price for alcohol Offer interventions for alcohol AUDIT CAGE Raise public awareness Treat alcohol dependence Clear unit information on alcoholic drinks Stop special offers Stop advertising to young people Lower recommended limits Alcohol liaison nurses ```

Question 237

Ways to reduce viral hepatitis

Answer 237

``` Hep B vaccine Antenatal testing for Hep B and C Test in prisons Needle exchange programs Free barrier contraception ```

Question 238

Limiting additional damage in chronic liver disease

Answer 238

``` Alcohol cession Low sodium diet Healthy diet Avoid infections - immunise for hepatitis, influenza, pneumonia Care RE over the counter drugs Weight loss ```

Question 239

Cancer care UK

Answer 239

3 levels of care - Primary care ``` - Cancer UNITs for populations of 250,000 Treat common cancers Diagnostic procedures Common surgery Non-complex chemotherapy ``` - Cancer CENTRES for populations of 1,000,000 Treat rare cancers Radiotherapy Complex chemotherapy Palliative care runs alongside all 3 levels

Question 240

Cancer networks

Answer 240

Established in 2000 28 cancer networks in the UK Work in local areas with clinicians, patients, managers to deliver the National Cancer Strategy to improve performance of cancer services Becomes known as Strategic Clinical Networks from 2013 - Now wider than cancers - One per region - Seeks to reduce inequalities in care

Question 241

Cancer plan 2000

Answer 241

4 aims - Save more lives - Ensure people with cancer get the right professional support and care as well as the best treatments - Tack inequalities in health - Build for the future through investment in the cancer work force - strong research and preparation for a genetic revolution

Question 242

Calman-Hine Report 1995 | Recommendations

Answer 242

All patients need to have access to a high quality of care Public and professional education into the early signs of cancer Patients, families and carers to be given clear information about the treatment and outcomes Cancer care should be patient centred Primary care is the central focus of cancer care Psychological aspects need to be recognised Cancer registration and monitoring

Question 243

Commitments and recommendations made to improve cancer care and reduce cancer

Answer 243

Lower smoking rates Reduce waiting times 5 fruit and veg a day National school fruit scheme - free piece of fruit for children 4-6 at school Raise public awareness Cancer screening Increased funding for palliative care nurses and MacMillan nurses Investment in staff and equipment Cancer networks to improve experiences Extra funding for hospices End postcode lottery - NICE recommended drugs available to all health authorities