Week 0/15 - GP Flashcards

Question

Why is it important to contact health visitors, social work, teachers etc. as a GP if you have concerns about a child/family?

Answer 1

As a doctor it is your duty to share info w/ other professionals and agencies to safeguard children.

Answer 2

* Domestic abuse * Parental alcohol and drug misuse * Child/adolescent mental health difficulties * Parental mental health difficulties * Children with disabilities * Non-engaging families * Female genital mutilation * Harmful or problematic sexual behaviour * Honor based violence and forced marriage * Fabricated or induced illness * Child trafficking * Hidden children * Under-age sexual activity * Children or young people who are missing

Answer 3

* Initiate a Notification of Concern * If there is enough info at time of consult and concern other professionals and agencies to do so * Be open and honest with parents about the notification * Main reasons for NOC - children may come to significant harm from domestic abuse and neglect if the appropriate intervention is not sought * Used to guide health care staff on how to raise a concern

Answer 4

* All initial referrals regarding NOC should be made to social work by telephone - allows for discussion of case with team leader, decide appropriate action * If child or children are felt to be in danger - contact the police on 999 * NOC referral form must be made electronically to the CPU and social work * Sent via secure email and a copy should be appended to each of the children's medical files - all concerns recorded chronologically * Written documentation needs to be submitted within 48 hours of a notification being raised * Family should be discussed at practice in CP meeting, liaise with CP lead in practice - all children coded as 'vulnerable' until further information is accrued

Answer 5

Abuse - form of maltreatment of a child * Somebody may abuse or neglect a child by inflicting harm or by failing to act to prevent harm

Answer 6

* Physical abuse * Deliberate act to harm a child which causes bruises, cuts, burns or broken bones * Babies - shaking or hitting them can cause non-accidental head injuries * Can have serious consequences for children - can grow up and cause long lasting harm * Sexual abuse * Age of consent is 16 years old, below that age young person cannot consent to sexual acts * Forcing or enticing a child or young person to take part in sexual activities * Emotional abuse * Psychological abuse * Ongoing emotional maltreatment - deliberately trying to scare or humiliate a child, isolating or ignoring a child * Often happens at the same time as neglect or other abuse * Neglect * Persistent failure to meet a child's basic physical and/or psychological needs, likely to result in serious impairment of child's health or development * Can occur during pregnancy e.g. through maternal substance abuse and after birth through a variety of mechanisms

Answer 7

* When a child requires protection from child abuse or neglect * Not required that abuse/neglect has taken place, but a risk assessment has identified a likelihood or risk of significant harm from abuse or neglect * Child protection register - central register of all children, including unborn children held and maintained by local authorities * Has no legal status - administrative system * Can be accessed 24 hours a day by concerned professionals

Answer 8

* UN convention on the Rights of the Child (UNCRC) - one of the core international human rights treaties * Universally agreed set of minimum child rights standards from birth to age 18 years, came into force in 1992 in the UK * In Scotland, children's rights are protected under Children + Young People (Scotland) Act 2014 - implements the UNCRC * Scottish government produced GIRFEC - Getting it Right for Every Chuld * Outlines the principles and values to support children and young people, national approach to encourage the wellbeing of children in Scotland, based on UNCRC * Child Protection Improvement Plan implemented by Scottish government in 2016 to review CP procedures and legislation * Main focus is to raise awareness of emotional abuse and child neglect * Resulted in revision of Section 12 of Children and Young Persons (Scotland) Act 1937 - child cruelty provision * The legal responsibility to investigate child protection concerns is the remit of social work and police

Answer 9

* When information is shared a record must be made of who the information has been shared with, the reasons for doing so and if informed consent was gained or not * If decision is made not to share information this also needs to be recorded * If families move between authority areas (temporarily or permanently) then immediately the original authority will notify the receiving authority, must be followed up in writing

Answer 10

* All doctors must take action if they believe a young person may be being abused or neglected * You must tell an appropriate agency e.g. local authority children's services, NSPCC or police promptly if you are concerned that a child/young person is at risk of/is suffering abuse or neglect, unless it is not in their best interest to do so * You do not need to be certain - the possible consequences of not sharing relevant information will, in the overwhelming majority of cases, outweigh any harm that sharing concerns with an appropriate agency may cause

Answer 11

* You must do so by law or in response to a court order * The person the information relates to has given you their consent to share the information (or a person with parental responsibility has given consent if the information is about a child who does not have the capacity to give consent) * It is justified in the public interest - if the benefits to a child or young person that will arise from sharing the information outweigh both the public and the individual's interest in keeping the information confidential

Answer 12

* Innate - genetically pre-programmed * Soluble factors * Antibacterial factors * Complement system * Cellular factors * Scavenger phagocytes * Adaptive - immunological memory * Humoral * B cells * Cellular * CD4 T cells * CD8 T cells

Answer 13

1. Lysozyme * Enzyme present at mucosal surfaces e.g. resp/GI tract * Active in breaking down the Gram +ve cell wall 2. Lactoferrin * Protein found at mucosal surfaces * Bacteria need soluble iron for growth - lactoferrin chelates iron \> less soluble iron in GI/resp tract \> inhibited growth of bacteria

Answer 14

* Classical pathway - antigen:antibody complexes * MB-lectin pathway - lectin binding to pathogen surfaces * Alternative pathway - pathogen surfaces

Answer 15

* Initiation of complement activation – alternative, classical or MB-lectin pathway * Early steps – C3 binding to pathogen surface * C3a – inflammation * C3b – opsonisation and phagocytosis * C5a – inflammation * Late steps – complement protein form membrane attack complex à lysis of microbe (lesions form)

Answer 16

Pathogenic bacteria are often resistant to complement

Answer 17

* Monocyte (blood) --\> macrophages (tissue) * Tissue specific functions e.g. Kupffer cells in liver, microglia in CNS, alveolar macrophages, sample and destroy small numbers of pathogens they come into contact with

Answer 18

Macrophage Functions: * Clearance of micro-organisms * Getting help – when overwhelmed sends hormonal signals to summon more immune cells How do they do this: * Phagocytosis * Specialised in destruction of pathogens, also removed harmless debris e.g. tattoo pigment * Antigen presentation * Process engulfed particles, travels to draining lymph nodes and presents to T cells in MHC II * Cytokine production * M1 – inflammatory e.g. TNF alpha * M2 – regulatory e.g. IL-10

Answer 19

* Genetically hardwired * Recognise molecules found commonly in micro-organisms * Able to recognise extracellular and intracellular threats * Respond to bacteria, fungi and yeasts

Answer 20

* Toll-like receptors e.g. TLR1, 2, 6 etc. bind to peptidoglycans (gram +ve), lipoteichoic acids (gram -ve) * Initiate NF-kapaB, IRF and MAPK signalling, leads to IL-1B and TNF-alpha release

Answer 21

Innate fails due to highly pathogenic bacteria and/or structural failure e.g. renal stones

Answer 22

* ‘Foot soldier’ of the immune system * 50-70% of WBC * Rapid response to infection

Answer 23

* Chemotaxis – migrate towards bacterial products e.g. lipopolysaccharide, chemokines and ‘danger’ signals e.g. complement components * Degranulate – release toxic granules + hydrogen peroxide extracellularly (principal method of bacteria destruction) * Phagocytic – will ingest and destroy pathogens using proteases, reactive oxygen species, lysozyme etc. * Die locally producing characteristic pus

Answer 24

* Classically respond to parasites * 1-6% of WBC * Pathological role in allergy

Answer 25

* Chemotaxis – migrate in response to chemokines e.g. eotaxin * Degranulation – release toxic substances onto the surface of parasites e.g. major basic protein, eosinophil cationic protein, eosinophil peroxidase * Cytokine production – drives inflammation e.g. IL-1, 2, 4, 8, TNF-alpha Irritant toxin proteins released cause pruritis

Answer 26

* Basophils (blood) à mast cells (tissues) * ‘Border guard’ of immune system, guard mucosal sites * Important role in allergy

Answer 27

* Degranulation – rapid release pre-formed granules containing cytokines and mediators e.g. histamine (triple response wheal + flare reaction) * Cytokine release – store many pre-formed cytokines ready for release to attract + drive immune response

Answer 28

* Typical branching structure e.g. Langerhans’s cells in epidermis * Derived from monocytes * ‘Sentinel’ of immune system – sample tissues looking for stranger/danger * Prototype antigen presenting cell

Answer 29

* Phagocytosis – unlike macrophages not specialised in destruction of pathogens, mainly function as antigen presenting cells * Migration – in tissues constantly sampling environment, when active will travel to draining lymph nodes * Antigen presentation – presents to CD4 T cells and can initiate an adaptive immune response

Answer 30

1. Dendritic activation * Stranger model – pathogen associated molecular pattern recognised by pattern recognition receptor on dendritic cell * Danger model – necrotic cell death causes release of danger associated molecular patterns, recognised by DAMP receptor on dendritic cell 2. Dendritic cell maturation 3. Conformational change from sampling to presenting - peptide-MHC complex forms, CD80 and/or CD86 co-stimulatory molecule needed 4. Migration to draining lymph node 5. Dendritic cell binds to T-cell receptor, activates T cell

Answer 31

* Humoral * B cells --\> antibodies (immunoglobulins) - extracellular pathogens e.g. bacteria * Cellular * CD4 T cells * Helper T cells * Directs B cells and CD8 T cells * Cytokine secretion * CD8 T cells * Killer or cytotoxic T cells * Targets intracellular pathogens e.g. viruses

Answer 32

* Opsonise for phagocytosis * Activate complement for lysis * Neutralise toxins and pathogen binding sites

Answer 33

* Antibody expressed on cell surface = B cell receptor * Following stimulation, antibodies released into circulation

Answer 34

* Differ in Fc regions IgM * Main antibody of primary immune response * Low affinity, many binding sites * Activates complement IgG * Main antibody of secondary immune response * Higher affinity as part of secondary response - memory * Activates complement, binds Fc-gamma receptor on phagocytes (opsonises) * Crosses placenta IgA * 'Antiseptic paint' * Present in secretions and lines epithelial surfaces * Neutralises by blocking binding of pathogens IgE * High affinity binding to mast cells through Fce receptor * Role in allergy

Answer 35

* Antigen recognition * Activation due to helper T cells, other stimuli * Clonal expansion, differentiation * Effector cells - antibody-secreting plasma cells * IgG expressing B cell (isotype switching) * High affinity Ig-expressing B cell * Affinity maturation - high affinity IgG * Memory B cell

Answer 36

* Initial immune response – lots of IgM produced, low affinity binding * As immune response progresses isotype switching occurs, more IgG, higher affinity

Answer 37

* Primary response * 5-10 day lag after immunisation * Peak response smaller * Antibody type usually IgM \> IgG * Antibody affinity - lower average affinity, more variable * Secondary response * 1-3 day lag after immunisation * Peak response larger * Relative increase in IgG and, under certain situations, in IgA and IgA (heavy chain isotype switching) * Antibody affinity - higher average antibody affinity (affinity maturation)

Answer 38

Optimal B cell response requires T cell help for: * Clonal expansion of specific B cells * Progression to antibody secreting (plasma) cells * Progression to memory B cells * Isotype switching to IgG, IgA and IgE * Affinity maturation

Answer 39

* Receptor on surface of T cells, recognises antigen when presenting in MHC molecule * Recognises short peptide lengths, not whole 3D molecules (antibodies can recognise whole 3D macromolecules)

Answer 40

* Gene splicing and recombination leads to formation of many unique T cell receptors

Answer 41

* B cells * Develop in bone marrow * If B cell receptor binds strongly to ‘self’ antigen in bone marrow – B cell dies by apoptosis * T cells * Originate in bone marrow à thymus * If T cell receptor binds strongly to ‘self’ antigen in thymus – T cell dies by apoptosis * Activation of both cell types requires presence of danger signals to activate * If antibody/TCR engaged in absence of ‘second signal’ cell likely to become anergic

Answer 42

* T cells only see antigen in context of MHC * Class 1 MHC * Presents to CD8 T cells - causes death of infected cell * On all nucleated cells * Presents intra-cellular antigen via endoplasmic reticulum * Alpha 1, 2, 3 and Beta 2 microglobulin chains * Class 2 MHC * Presents to CD4 T cells - causes cytokine release * Presents extra-cellular derived antigen (phagocytosed - endocytosis into vesicle) * Found on antigen presenting cells - dendritic cells, macrophages, B cells * Alpha 1 and 2 and Beta 1 and 2 chains

Answer 43

* TH1 cells - IFN-gamma secretion, host defense against intracellular microbes, inflammation * TH2 cells - IL-4, 5, 13 secretion, host defense against helminths, allergic reactions * TH17 cells - Il-17 secretion, host defense against some bacteria, inflammatory disorders * T regulatory cells - act to regular function of other immune cells, in particular T cells

Answer 44

* Primary organs * Thymus – T cell maturation * Bone marrow – B cell maturation * Secondary organs * Lymph nodes * Spleen * Mucosal associated lymphoid tissue of GI tract and bronchial tract

Answer 45

Germinal centres and paracortical areas swell significantly

Answer 46

* Similar function to lymph nodes * Filters blood of senescent (old, deteriorating) cells and blood borne pathogens * Important in response to encapsulated organisms and blood borne pathogens

Answer 47

* Provides specific antibodies to innate to enhance pathogen clearance * Provides cytokines to innate to upregulate activity * Finishes clearing pathogens * Develops memory to prevent future infection

Answer 48

* Memory B and T cells already present at high frequency * Memory lymphocytes have lower threshold for activation and actively patrol sites of previous pathogen entry * Preformed antigen specific IgA prevents pathogen binding * Preformed high affinity IgG rapidly opsonises pathogen for phagocytosis

Answer 49

* Innate immune response * 'Danger' signals triggered via PAMP receptors - complement activated * Dendritic cells and macrophages detect pathogens and are activated * Local mediators e.g. histamine released, chemotaxis triggered * Neutrophils arrive at site of infection, begin phagocytosis * Dendritic cells leave via lymphatics carrying antigen * Activation of adaptive immune response * Dendritic cells to local draining lymph node * Circulating T cell enters from high endothelial venules of lymph node and engages dendritic cell via TCR * Adaptive immune response * CD4 T cells provides cytokines to activate CD8 T cells and antigen specific B cell * B cell takes up antigen via BCR, presented on MHCII * Some B cells go to medullary cord and become antibody secreting plasma cells * Other B cells enter lymphoid follicle to form germinal centre + undergo affinity maturation

Answer 50

* Type I * Immediate, atopic * IgE mediated * Type II * Cytotoxic, antibody dependent * IgM or IgG bound to cell/matrix Ag * Type III * Immune complex * IgM or IgG bound to soluble Ag * Type IV * Cell mediated * T cells (CD4 and CD8) * Type V * Receptor mediated * IgM or IgG bound to receptors * Can be considered subset of type II All examples of adaptive immune response - sensitisation of the immune system must occur

Answer 51

* 'Classic' allergy - immune mediated noxious response to substance body is sensitized to * Specific characteristics * Response to challenge occurs immediately - if more than 24 hours post-exposure not type 1 * Tends to increase in severity w/ repeated challenge * Predominantly mediated by IgE bound to mast cells - degranulate releasing toxins which cause damage * Responsible for most allergies - asthma, eczema, hay fever

Answer 52

1. Sensitization 2. Mast cells primed with IgE 3. Re-exposure to antigen 4. Antigen bind to IgE associated w/ mast cells 5. Mast cells degranulate releasing: * Toxins i.e. histamine * Tryptase * Pro-inflammatory cytokines * Chemokines * Prostaglandins * Leukotrienes 6. Proinflammatory process stimulates and amplifies future responses

Answer 53

* Early phase * Occurs within minutes of exposure to antigen * Occurs largely as a result of histamine and prostaglandins * Smooth muscle contraction * Increased vascular permeability * Late phase * Occurs over hours to days after exposure to antigen * Principally mediated through recruitment of T-cells and other immune cells to site by cytokines * Sustained smooth muscle contraction/hypertrophy * Tissue remodelling

Answer 54

* Severe, systemic type I hypersensitivity * Widespread mast cell degranulation caused by systemic exposure to antigen i.e. penicillin * Vascular permeability is principle immediate danger - can be rapidly fatal * Soft tissue swelling threatening airway * Loss of circulatory volume causing shock

Answer 55

* Caused by binding of antibodies directed against human cells * IgG usually cause (+IgM, IgA)

Answer 56

* Uncommon cause of allergy - drug associated haemolysis * Common cause of AI disease * Bullosa pemphigoid common type II hypersensitivity * Loss of skin integrity - IgG autoantibodies bind to basement membrane * Characteristic skin blistering

Answer 57

* Sensitization * Opsonization of cells * Cytotoxicity * Complement activation * Inflammation * Tissue destruction * In some cases: * Direct biological activation with antigen i.e. receptor activation, impaired enzyme action

Answer 58

* Mediated by immune complexes bound to soluble antigen * Multiple binding sites on antibodies, immune complexes form

Answer 59

* Cause of autoimmune disease and drug allergy * Aggregate in small blood vessels e.g. glomerular capillaries * Direct occlusion * Complement activation * Perivascular inflammation

Answer 60

* Also known as delayed type hypersensitivity * Presents several days after exposure * E.g. nickel allergy to jewellery * Mediated by the action of lymphocytes infiltrating area - CD4/8 cells * Thickened epidermis * External substance enters body and alters conformation of self-cells (contact sensitizing agent)

Answer 61

1. Contact-sensitizing agent penetrates the skin and binds to self proteins, which are taken up by Langerhans cells (DC) 2. Langerhans cells present self peptides haptenated with the contact sensitizing agent to TH1 cells, which secrete IFN-gamma and other cytokines 3. Activated keratinocytes secrete cytokines such as IL-1 and TNF-alpha and chemokines such as CXCL8, CXCL11 and CXCL9 4. The products of keratinocytes and TH1 cells activate macrophages to secrete mediators of inflammation

Answer 62

* Inflammatory response directed against 'self' tissue by the adaptive immune response * Organ specific * Systemic * Most don't fit into one category of hypersensitivity

Answer 63

* Type 1 Diabetes * Selective, AI destruction of pancreatic B cells * Often mix of type II/IV * Causes profound insulin deficiency and death if not treated w/ insulin replacement * Inflammation of Islets of Langerhans precedes symptoms by many years * Myasthenia Gravis * Syndrome of fatigable muscle weakness * Limbs * Respiratory * Head and neck * Caused by IgG against Ach receptor - antibody blocks receptor and prevents signal transduction

Answer 64

Many varieties of systemic AI disease e.g. * Rheumatoid arthritis * Systemic lupus erythematosus * Inflammatory bowel disease * Connective tissue disease * Systemic vasculitis

Answer 65

* Genetic predisposition * Environmental factors * Recognition of self antigens by the immune system as foreign * Persistence of inflammatory response to develop chronic disease

Answer 66

* MHC-I and II (HLA locus) * Cytokines and receptors i.e. TNF-alpha * Other immune associated genes e.g. transcription factors, cell adhesion molecules

Answer 67

* Infection * Molecular mimicry * Pathogenic antigens so similar to self-antigens they get confused – antibodies produced on infection * E.g. S pyogenes similar to epitopes on cardiac myotome = myocarditis, valvular heart disease * Geographical factors * Vitamin D levels mediated through sunlight exposure * Modifiable personal risk factors * Smoking

Answer 68

* Presence of antibodies of citrullinated proteins strongly predicts RA * Citrullinated proteins develop due to action of enzymes induced during inflammation * Smoking associated with conversion of alanine to citrulline * Combination of smoking history and genotype = high risk of RA

Answer 69

* Psychiatric equivalent of physical exam * Objective observations by clinician and subjective descriptions by patient * Should link to patient’s history – cultural, education etc., what is normal for the patient

Answer 70

* Snap shot of point in time * Help with diagnosis * Change over time e.g. in response to treatment * Describe patient to another doctor who doesn’t know them

Answer 71

1. Appearance and behaviour 2. Mood and affect 3. Thought (form and content) and speech (RISK) 4. Perception 5. Cognition 6. Insight and judgement

Answer 72

* Appearance * Gender, ethnicity, build, dress, posture, grooming, prominent physical abnormalities * Rapport * Established or not * Level of alertness * Drowsy, alert (delirium, intoxicated) * Attitude * Co-operative, aggressive, abusive, over-familiar (e.g. manic) etc. * Eye-contact * Good, poor, intense * Psychomotor activity * Retardation, agitation * Movements * Tremor, abnormal movements * Other signs * Tics, mannerisms (odd purposeful movement), stereotypes (non-goal directed movements)

Answer 73

* Mood = pervasive subjective feeling state communicated by patient (0-10) - ‘climate’ * Affect = current observed emotional state, objective and less pervasive - ‘weather’ * Elated * Apathetic * Angry * Dysphoric

Answer 74

* Congruence, reactivity and stability of affect - blunted, flat, labile * Range of reactivity

Answer 75

* Schizophrenia – incongruent, blunt, restricted * Mania – euphoric, ecstatic, expansive, labile * Major depressive disorder – sad, low, restricted

Answer 76

* Quantity – talkative, spontaneous, expansive, paucity, poverty * Rate – fast, slow, normal, pressured * Volume (tone) – loud, soft, monotone, weak, strong * Fluency and rhythm – slurred, clear, w/ appropriately placed inflections, hesitant, w/ good articulation, aphasic

Answer 77

* Form – flight of ideas * Content – delusions of grandeur * Stream and flow – pressure of speech * Possession – patients own thoughts

Answer 78

* Clanging and punning * Flight of ideas * Loosening of association * Circumstantial * Tangentiality * Disorder of flow * Retardation of thinking – slow thought train, increased pauses * Pressure of speech – excessive thoughts, rapid voluminous speech * Perseveration – response continues even if stimulus changes

Answer 79

* Overvalued ideas – high importance but shakeable belief * Delusions – false fixed firm belief * Held in spite of evidence to contrary * Not in keeping with cultural and educational setting * Paranoid – self-referential (most delusions are)

Answer 80

* Delusions of persecution e.g. psychotic delusions * Delusions of reference – messaged from TV, radio etc directed towards individual * Delusions of grandeur – chosen one * Nihilistic delusions – severe mood disorder, part of body dead, poverty * Hypochondriacal delusions * Delusions of jealousy

Answer 81

* Thought insertion * Thought withdrawal * Thought broadcast * Thought blocking * Obsessions Common in psychosis

Answer 82

* Recurrent and persistent ideas, thoughts, impulses or images * Intrusive, cause marked anxiety/distress – not simple excessive worries * Attempts to ignore/supress unsuccessful * Recognised as own thoughts * Usually ego-dystonic

Answer 83

* Repetitive behaviours or mental acts * Driven to perform * Response to obsession * Aimed at * Preventing/reducing distress * Preventing dreaded event/situation

Answer 84

* Can include in thought content/mood * Risk to self – suicidal ideas, plans/intent, ability to manage day-to-day needs, self-care etc * Risk to others – thoughts of harming others, driving risk etc.

Answer 85

* Reception and processing of sensory information * Visual - sight * Auditory - hearing * Tactile - touch * Gustatory - taste * Olfactory - smell * Can have abnormalities of perception in all 5 senses

Answer 86

* Hallucination - perception without stimulus * Distortion - quality of perception altered e.g. visual * Illusion - stimulus present but different objext perceived * Negative hallucination - stimulus present, no object perceived

Answer 87

* Psychotic and affective illnesses * Elementary - hear noises * First person - unusual * Second person - separate person saying things * Third person - two people talking

Answer 88

* Consider underlying organic cause * Lilliputian * Charles Bonnet syndrome * Hypnogogic and hypnopompic - can be normal

Answer 89

* Cognition (ORAAL - orientation, registration and recall, attention, apraxia, language) * How we take in information, process it and use it in our daily activities: * Attention * Ability to sustain focus * E.g. serial 7s * Orientation - T/P/P * Time - day, date, season, month, year * Place - building, place, floor, country * Person - name/doB * Memory * Ability to retain information * Verbal - remember 3 words and repeat * Executive function * Planning, abstract thinking, initiating appropriate actions, inhibiting inappropriate actions, includes judgement * Ask patient to problem solve - what would you do if you lost your keys/if there was a fire * Language and praxis

Answer 90

* Awareness of one's symptoms * Attribution of symptoms to mental disorder * Appraisal or analysis of consequence of the disorder * Acceptance of treatment * Continuum rather than all or nothing - no, partial or full insight, can vary with mental state * Intellectual insight - recognise illness but no emotional understanding

Answer 91

Includes * Rough sleeping/street dwelling * Sofa surfing * Vulnerable housing situation e.g. living w/ domestic violence, debt

Answer 92

* Conflict * Natural disasters * Housing provision * Welfare provision

Answer 93

* Disrupted family life (poverty, abuse, into care) * Poor educational attainment * Poverty * Experiences of violence * Addictions * Mental health problems * On-going risky relationships

Answer 94

* 2/3 people in homelessness services in England also in criminal justice or addiction treatment services in the same year * Experiencing childhood adversity, alarming levels of loneliness, isolation, unemployment, poverty and mental ill-health are considerably worse for those in overlapping populations

Answer 95

PTSD - symptoms \>1 month Complex PTSD - recurrent trauma (e.g. domestic abuse), symptoms worse

Answer 96

* Depression, crying * Numbness * Nightmares * Guilt * Triggers * Hypervigilance – on edge, startled easily * Alcohol + drug abuse * Self harm * Dissociation – detachment from reality

Answer 97

* Individual psychology * Individual activity * Activity environment * Biology * Food production * Food consumption * Societal influences

Answer 98

* Insulin, sulphonylureas, thiazolidinediones - diabetes * Beta blockers - hypertension * Corticosteroids - inflammatory disease * Cyprohaptadine - allergy, hayfever * Antipsychotics - psychosis * Sodium valproate - epilepsy * Tricyclic antidepressants - depression * Lithium - bipolar disorder

Answer 99

* Risk factors e.g. blood pressure levels and alcohol consumption are normally disributed throughout the population (bell curve) * Targeting prevention and treatment as those with the highest levels of risk will reduce individual risk but not contribute to substantial reductions in population risk * Adopting universal prevention measures shifts the population mean to the left, preventing disease in a large population of people at low risk and reducing the proportion of people above the treatment threshold

Answer 100

* Population Strategies for Obesity: * Education campaigns * HFSS (high fat, salt, sugar) food advertising * Weight stigma and discrimination * High Risk Individual Strategies for Obesity: * Education, employment and income influence obesity risk * Community Strategies for Obesity: * Cycling infrastructure * Opportunities for exercise

Answer 101

* Tier 1 - population wide intervention and prevention initiatives * Information and guidance on healthy eating and physical activity * Tier 2 - community weight management service * Multicomponent weight management services including primary identification, assessment and lifestyle interventions * Tier 3 - specialist weight management services * Multi-disciplinary specialist treatments, including pharmacotherapy, psychological assessment and low calorie diets * Tier 4 - surgical interventions * Pre-op assessment, bariatric surgery, post-op care

Answer 102

* Targets for weight loss based on comorbidities and risks rather than weight alone (SIGN) - target those at highest risk. * In patients with BMI 25-35kg/m2 obesity-related comorbidities are less likely to be present * In patients with BMI \>35kg/m2 obesity-related comorbidities are more likely to be present * 5-10% weight loss (approximately 5-10kgs) is required for cardiovascular disease and metabolic risk reduction.

Answer 103

* Diet: 600 kcal deficit; higher protein/ lower carb = better adherence (Larsen NEJM 2010) * Physical activity: 45-60 mins moderate intensity/day * ~2000 kcal/ week * Behaviour change: Self monitoring; stimulus control; goal setting; relapse prevention * Additional interventions considered where appropriate * Psychological support * Specialised liquid diet * Medication * Surgery

Answer 104

* BMI \>25 (22.5\*) + impaird fasting glucose/impaired glucose tolerance/high risk of T2DM, T2DM * BMI \>30 (27.5)\* + T1DM/T2DM/existing CVD/mobility issues/weight loss required pre-surgery * BMI \>40 no co-morbidity required * \>180kg no co-morbidity required \* patients with South Asian/Chinese/Middle Eastern ethnicity have a lower BMI threshold

Answer 105

* Patients * Location/timing of classess * Lack of awareness of service * Delay between referral - assessment - classes * Lack of cultural awareness * Practitioners * Lack of awareness of nearest centre * Lack of confidence in service * Lack of knowledge of what service involves * Opt-in process felt to be a barrier * PNs better placed to discuss weight than GPs

Answer 106

The standard for respectfully addressing people with chronic disease, rather than labelling them by their illness

Answer 107

Workload of healthcare for individuals managing long-term health conditions and the impact on wellbeing Arises as a Consequence of: * Workload volume * Care deficiencies

Answer 108

Illness Work = the 'work' that the patients and their families do to understand and 'live with' a chronic illness Treatment work = tasks that need to be performed to manage health and follow treatments set by healthcare providers

Answer 109

* Poor adherence * Disengaging from health services * Poorer quality of life A self-perpetuating cycle - treatment burden high --\> poor adherence --\> worse health oucomes --\> escalated treatments from healthcare providers --\> higher treatment burden

Answer 110

* Sense making work * Understanding treatments/disease * Relationship work * Interact w/ wide range of HCP * Interact w/ family and friends - help with getting to appointments, picking up prescriptions * Enacting work * E.g. intense regular physiotherapy * Reflective work * How are they progressing? * What do they need to do going forward?

Answer 111

258 million * 4.8 million students * 150.3 million migrant workers * 25.4 million registered refugees

Answer 112

International migrant population globally has increased in size but remained relatively stable as a proportion of the world's population

Answer 113

* Family reasons * Work * Education * Other

Answer 114

What shapes people's knowlege of, and access to, services

Answer 115

* Asylum process * Refugee experience * Language * The environment * Experiences of racism * Cultural norms about meanings of health * Access to social resources * Access to financial resouces

Answer 116

* Reporting on migration and migrants a constant presence in UK (English-based) media * Many “voices” reported – politicians predominated * Right leaning papers draw on anti-migrant think tanks * Often more sympathetic to individual migrants, than to migration per se * Less sympathetic when group “faceless” – unclear or mixed group * Fairly sympathetic towards ASR women – individuals stories Major themes: * Migrants are a threat to UK culture * Migrants are over-running the NHS * UK citizens are disadvantaged by migration

Answer 117

Safe surgeries - nationality or immigration status does not affect right to register at a GP practice * Offer interpreter if difficult to communicate in English * Receptionists don't ask about immigration status * Offer advice if worried about giving address - confidentiality

Answer 118

The science of the rate of movements of drugs within biological systems, as affected by the absorption, distribution, metabolism and elimination of medications. 'What your body does to the drug'

Answer 119

Study of the underlying biochemical and physiologic processes underlying drug action * Mechanism of drug action * Drug-receptor interaction * Efficacy * Safety profile 'What the drug does to your body'

Answer 120

Fraction of the administered dose of drug that reaches the systemic circulation, expressed as letter F.

Answer 121

* Drug factors * Molecular weight/localisation * Absorption * Gastric pH/health of GI tract * First pass metabolism (hepatic) * Phenytoin may reduce F * Grapefruit juice may increase F

Answer 122

Theoretical volume that drug is spread out in * Smaller volume if stay intravascular * Larger volume if interstitial

Answer 123

Volume of plasma 'cleared' of drug per unit time (e.g. ml/min or L/h)

Answer 124

Time required for serum plasma concentration to decrease by half

Answer 125

Determined by clearance and volume of distribution * VD is the volume in which the amount of drug would need to be uniformly distributed to produce observed blood concentration

Answer 126

4-5 half lives to reach steady state Loading doses often used for drugs with long half-life

Answer 127

Time for concentration to fall to half

Answer 128

Clearance and volume of distribution T1/2 = 0.693 x V/CL

Answer 129

* Time to eliminate drug * Time to reach steady state * Dosage interval

Answer 130

Concentration that results from a dose is proportional to the dose * Double the dose, double the concentration Rate of elimination is proportional to the concentration * 50% of drug will be eliminated in a given time frame

Answer 131

* Concentration that results is not proportional to dose * Rate of elimination is constant regardless of amount of drug present * Dosage increases can saturate binding sites and result in non-proportional increase in drug levels * Or opposite in dose decrease E.g. alcohol, phenytoin

Answer 132

* Decrease in total body water (due to decrease in muscle mass) and increase in total body fat affects volume of distribution * Water soluble drugs - lithium, aminoglycosides, alcohol, digoxin * Serum levels may go up due to decreased volume of distribution * Fat soluble - diazepam, thiopental, trazadone * Half life increased with increase in body fat * Absorption - not highly impacted by aging * Variable changes in first pass metabolism due to variable decline in hepatic blood flow * Typically reduced with age but variable

Answer 133

* Acetylation and conjugation do not change appreciably with age * Oxidative metabolism through cytochrome P450 system does decrease with aging, resulting in a decreased clearance of drugs * Hepatic blood flow variable

Answer 134

* GFR generally declines with aging, but is extremely variable * 30% have little change * 30% have moderate decrease * 30% have severe decrease * Serum creatinine is an unreliable marker * If accuracy needed, do Cr Cl

Answer 135

Biochemistry use MDRD equation to calculate eGFR - done on U&E results Pharmacists usually use Cockroft and Gault Cr Cl = 140-age(yrs) x wt (kg) x.85 for women Cr (mg/100ml) x 72 May overestimate Cr Cl, especially in frail elderly people

Answer 136

* Some effects are increased * Alcohol * Opiates * Sedatives * Theophylline * Some effects are decreased * Diminished HR response to isoproterenol and beta-blockers

Answer 137

* About 15% of hospitalisations in elderly related to adverse drug reactions * More medications a person is on, higher risk of drug-drug interactions or adverse drug reactions * More medications a person is on, higher the risk of non-adherence

Answer 138

* Statins and clarithromycin and other antibiotics * Verapamil and beta-blockers – complete heart block * Warfarin and multiple drugs (incl aspirin) * ACE inhibitors increase hypoglycemic effect of sulfonylureas

Answer 139

* Patient with PD have increased risk of drug induced confusion * NSAID (and COX-2’s) s can exacerbate CHF * Urinary retention in BPH patients on decongestants or anticholinergics * Constipation worsened by calcium, anticholinergics, calcium channel blockers * Neuroleptics and quinolones lower seizure thresholds

Answer 140

* CAD * Beta blockers * Aspirin * Anticoagulation in AF * HTN, especially systolic HTN * Pain * Particular fear of narcotics in the elderly

Answer 141

* NSAID -\> HTN -\> antihypertensive therapy * Metoclopramide -\> parkinsonism -\> Sinemet * Dihydropyridine -\> oedema -\> frusemide * HCTZ -\> gout-\> NSAID -\> 2nd antihypertensive * Sudafed -\> urinary retention -\> alpha blocker * Antipsychotic -\> akathisia -\> BDZ

Answer 142

* Decreased elimination * Aminoglycosides * Lithium * Digoxin * Methotrexate * Penicillins * Decreased protein binding * Decreased hepatic metabolism

Answer 143

* Altered sensitivity to drug effect * Increased sensitivity to sedatives * Adverse effects * ? Altered BBB permeability

Answer 144

Determination of renal function --\> alteration of dosing schedule --\> monitoring drug concentrations

Answer 145

* Renal failure leads to acid retention * “Acidic” drugs less bound to albumin: * Conformational change in albumin, less ionised drug to bind * Increased free (active) drug in plasma * Usually of little clinical relevance; * Phenytoin (acidic) * Less bound drug (more free drug) * Target concentration lower in renal failure * Increased clearance by HD

Answer 146

* Hepatic metabolism of some drugs is slower in renal failure * ? Endogenous inhibitor in uraemic plasma * Normalised by HD

Answer 147

* Nephrotoxins - amphotericin, gentamicin * Fluid retention - NSAIDs * Increasing uraemia - tetracyclines * Electrolyte disturbance - amiloride, digoxin

Answer 148

* Antibiotics (reduce dose) * LMWH (reduce dose) * Metformin (avoid) * NSAIDs (avoid) * Digoxin (reduce dose) * Phenytoin (reduce dose) * ACE Inhibitors (caution)

Answer 149

* Same hepatic metabolism * Same/increased VD and prolonged elimination (T1/2 increased) * Thus, increased dosing interval

Answer 150

* First pass metabolism * Activation of prodrugs * Decreased protein binding * Decreased elimination * Difficult to predict, many factors involved * No simple test (compared to Cr Cl in renal impairment)

Answer 151

Altered sensitivity to drugs * Sensitivity to sedatives * Sensitivity to oral anticoagulants * Precipitation of encephalopathy * Fluid retention * Hepatorenal syndrome

Answer 152

* Profound changes in bioavailability * Chlormethiazole (1000% increase) * Verapamil (140% increase) * Paracetamol (50% increase) * First pass activation reduced: * Enalapril, perindopril etc. (prodrugs)

Answer 153

* High extraction * Metabolised at high rate by liver * Rate varies with delivery * Affected by changes in blood flow * Morphine, verapamil, lignocaine * Low extraction * Metabolised at low rate by liver * Independent of blood flow * Sensitive to changes in liver enzyme activity * Chloramphenicol, theophylline

Answer 154

Start w/ low dose, therapeutic drug monitoring

Answer 155

* Some antibiotics * Valproate * Warfarin * Sedatives * Verapamil

Answer 156

* Same renal elimination * Same/increased VD and slower rate of enzyme metabolism (T1/2/F increased) * Thus dosage reduced, dosing interval increased

Answer 157

Altered: * Absorption * Hepatic elimination * Renal elimination

Answer 158

* Achlorrhydria * Crohn's disease * Post-operative issues

Answer 159

* A history from an informant is necessary as often the patient cannot give a full history. * Cognitive – clarify duration of onset and progression * Memory problems, repetitive questions * Any difficulties with activities of daily living ADLs - washing, dressing, toileting, cooking. * Executive ADLS- shopping, paying bills, managing money, travelling * Behavioural- agitation, aggression, wandering, inappropriate behaviour, delusions and hallucinations * Psychological –mood/anxiety/sleep pattern-early morning wakening/concentration/lack of interest and motivation

Answer 160

* FBC, ESR, CRP - anaemia, vasculitis * TFTs - hypothyroidism * Bone profile - hypercalcaemia or hypocalcaemia * U&Es - renal failure, dialysis dementia * LFTs - alcoholism, metastatic disease * Glucose - diabetes * Vitamin B12 and folate - vitamin deficiency dementia * Lipid prolife - vascular dementia * HIV and syphilis not routinely checked for unless specific indication * Midstream specimen of urine - UTI ECG/CXR dependent on clinical history and examination findings

Answer 161

* \*Delirium * \*Depression * Alzheimer’s Disease * Vascular (multi-infarct) dementia * Dementia with Lewy bodies * Dementia secondary to an acute event, e.g. head injury/subdural haematoma * Pick’s disease * Chronic alcoholism * Hypothyroidism * Brain tumour * Hydrocephalus and normal pressure hydrocephalus * Creutzfeldt-Jacob disease * Huntington's chorea * Syphilis * Vitamin B12 deficiency * ’Dialysis dementia' secondary to aluminium intoxification \*most common differentials for suspected dementia - important to exclude

Answer 162

Anticholinergics Benzodiazepines Antipsychotics

Answer 163

* Contact social care if patient consents for assessmen of package of care - member of social care team visit patient at home to discuss what assistance they may require * Useful if family member or friend present to give collaborative history * Personal care for \>65s free in Scotland, under 65 standard charges apply * First line of support is usually local council but some patients and families utilise private home care for a fee

Answer 164

Patient acutely confused or has an affective disorder

Answer 165

* Referral to memory clinic led by old age psychiatry team in patients over 65 * Patient assessed for dementia by specialist nurse and psychiatrist * Under 65 - referral to neurologist for further investigation * If dementia rapidly progressive an urgent referral should be made to the neurology service to exclude an organic illness e.g. tumour/CJD

Answer 166

* Patient must inform DVLA of diagnosis, if they are not able to do so then the GP must as soon as practically possible * Must be documented in patient's clinical notes * Mild cognitive decline - can have performance assessed annually * Free service, patients can be referred by GP or hospital consultant * Sometimes referred directly by DVLA

Answer 167

* Progressive neurodegenerative disease * Accounts for \>50% dementia seen in Western society * Predominantly affects elderly population

Answer 168

* Normally insidious onset and develops slowly but progressively over a number of years * First symptom usually forgetfulness - memory impairment * Life expectancy lowered by 3x that of population without AD

Answer 169

* Advancing age \>65 * Smoking * Excess alcohol * Head injury * High cholesterol * Low physical activity * Mental inactivity * Genetic link - variant of apolipoprotein E on chromosome 19

Answer 170

Clinical diagnosis, confirmation histologically on post-mortem of neurofibrillary tangles and senile amyloid plaques in brain

Answer 171

* Cognitive * Problems carrying out ADLs e.g. washing, dressing, toileting, making meals * As disease progresses executive ADLS e.g. travelling, handling money, paying bills, remembering medications * Over time will likely require increasing care, either at home or in supported living arrangement e.g. care home * Non-cognitive symptoms * Behavioural and psychological symptoms of dementia * Affect \>80% of patients with dementia over course of disease * Often become worse as disease progresses * Include * Agitation * Wandering * Aggression - verbal and physical * Jealousy * Depression * Delusions * Hallucinations

Answer 172

* Drug treatments shown to slow cognitive decline, dependent on severity of disease * Mild-moderate * Acetylcholinesteriase inhibitors (AchEI drugs) e.g. donepezil, rivastigmine, galantamine * Moderate-severe (or intolerant of AChEI drugs) * NMDA receptor antagonist - memtantine

Answer 173

* Main side effects - syncope, bradycardia, GI upset * Contraindications - cardiac conduction abnormalities (need ECG before commencing) * Dosge - rivastigmine twice daily, donepezil and galantamine once daily

Answer 174

* Main side effects - constipation/hypertension/dizziness * Contraindications - renal impairment * Dosage - daily

Answer 175

* Some evidence that both AChEI and memantine may delay the emergence of BPSD * Important to rule out stimulis that may be causing distress e.g. pain, ensure there is no reversible clinical cause * Environmental cause e.g. change of career may also be attributable * Treat depression in dementia w/ antidepressants, first line SSRIs e.g. sertraline * Consider antipsychotics for patients with dementia who are either: * At risk of harming themselves or others * Experiencing agitation, hallucinations or delusions that are causing them severe distress

Answer 176

* Group cognitive stimulation therapy * Group reminiscence therapy * Cognitive rehabilitation or occupational therapy which supports functional ability

Answer 177

* Home care provision as discussed * Occupational therapist * Voluntary organisations e.g. Alzheimer's society - with 24hr helpline AD support * Day care centre * Drop in centre * Support groups

Answer 178

* Not uncommon for relative to reduce working hours or stop work altogether to care for a family member with dementia - has consequences on their QOL * Support and advice through social services or citizens advice bureau (CAB) * Access to benefits for patient and carer(s) include * Attendance allowance * Carer's allowance * Council tax exemption

Answer 179

* Annual GP review - chronic disease management of dementia * Information sharing - discuss with patient at time of diagnosis who they wish to share information with (relative/carer or other services), should be documented in notes * Care plan - electronic log of patient wishes of care, need consent of the patient * Have discussion about advanced directes with the patient and family around the time of diagnosis - power of attorney

Answer 180

* POA is a legal document put in place for another person, known as an attorney to look after a patient's welfare and/or financial affairs * Preferably drawn up with patient still has capacity to make decisions * Must be certified by a medical practitioner, most commonly signed by their GP * Patient and appointed attorney (usually a family member) are interviewed before a POA is certified to ensure the patient has capacity and is not influenced by the attorney * Having a POA in place allows the patient's affairs to be looked after as their disease progresses and they inevitably start to lose capacity

Answer 181

Take 30 mintes before breakfast or another oral medicine, stand upright for 30 minutes after ingestion

Answer 182

Dyspepsia = epigastric pain or discomfort which may occur with early satiety, postprandial fullness, heartburn and regurgitation Group of symptoms not a diagnosis

Answer 183

* Peptic Ulcer Disease (PUD) * GORD * Gastric Carcinoma \* important to exclude given age if weight loss present * Pancreatic carcinoma * Gallstones * Acute/Chronic Pancreatitis * Drug-induced gastritis * Ischaemic bowel- mesenteric angina * Non-ulcer dyspepsia * Malabsorption syndromes * Intestinal Parasites * Systemic Diseases- DM/Hyperthyroidism/hyperparathyroidism/Connective Tissue Disease

Answer 184

Bleeding risk

Answer 185

Ankle swelling GI upset

Answer 186

GI upset, jaw necrosis, atypical femoral fractures

Answer 187

Bradycardia, lethargy

Answer 188

Nausea, GI upset

Answer 189

Potential overdose

Answer 190

* Gaviscon = alginate therapy for GORD * Contain sodium carbonate and caution should be taken in patients on salt restriction e.g. cardiac failure

Answer 191

* NSAIDs * Anticoagulants - warfarin, DOACs * COX2 inhibitors - celecoxib * Corticosteroids * SSRIs - sertraline, fluoxetine, citalopram * Calcium channel blockers - amlodipine, verapamil * Nitrates - ISMN * Antibiotics - doxycycline * Bisphosphonates * Nicorandil/digoxin/potassium chloride/levodopa/colchicine * Theophylline/aminophylline

Answer 192

Polypharmacy - multiple medications, commonly recognised as five or more medications which are prescribed to a patient at any one time

Answer 193

* Ageing population * Chronic disease burden (multi-morbidity) * Preventative medications in line with national guidelines e.g. anticoagulation in AF

Answer 194

* Multiple medications prescribed to optimise patient care * Polypharmacy can be detrimental to patient * Can lead to hospital admission and poor clinical outcomes * Adverse drug reactions occur when co-prescribing * Considerable cost to NHS and medication waste

Answer 195

* Appropriate polypharmacy - prescribing for a patient with multiple conditions whereby their medication regime can optimised and aligned with best evidence. * Inappropriate/Problematic polypharmacy - prescribing of multiple medications inappropriately or when the intended benefit of the medication is not realised.

Answer 196

Is it: * The right medication * For the right reason * At the right dose * By the right route (pill, liquid etc.) * At the right frequency * At the right time * At the right place

Answer 197

* Increasing age * Increasing frailty * Increased number of medications * Resident in a care home * High risk medicines * Approaching end of their lives * Deprivation

Answer 198

* Toolkits identify medications that may cause ADRs. * Several tools have been developed for prescribing in the elderly. * Beer’s Criteria, revised in 2012, mainly used in USA Hospitals. * STOPP/START is a common screening tool used in UK. * Recommended by NICE for optimisation of prescribing medicines safely and effectively. * A toolkit used within primary care in Scotland ‘7 steps to Appropriate Polypharmacy’. It involves an in-depth medication review with the patient (and carer) with a HCP - which can be GP or pharmacist.

Answer 199

* Advanced Pharmacists - experienced pharmacists working in GP now taking on polypharmacy reviews instead of GPs * Social Carers - with consent – carry out medication prompts * Write down when patient refuses medications or takes late. * If carers cannot access home - consider key safe * Locked cabinet to prevent patient accessing medication when not required to prevent overdose * District Nurses often attend patients with chronic disease condition. * Weight/HR and BP checked * Blood monitoring as required * E.g. Check Hb improving /dropping. * Renal function for apixaban * Health care assistants (HCAs) – increasingly taking on roles previously performed by district nurses. * Practice staff * Ensure patients are recalled for chronic health reviews