Week 10 Flashcards

Question

Disability, stigma and resilience The Missing Billion report

Answer 1

I perceive a need -> I decide to seek healthcare -> I reach healthcare venue -> I access healthcare services -> I engage with healthcare staff -> I receive treatment and follow up care

Answer 2

Map your network - social security, community leaders, nursing staff. Know your safeguarding and child safety policies and what to do. Communication. Attitude, Rights based approach. What that means as a healthcare worker: identify and tackle barriers across all levels, more and better data is needed, better inclusion services, better training of healthcare workers, better policies, laws, leadership and funding - and their enforcement, influence policy and programming

Answer 3

Worldwide access to end-stage kidney disease. 2.284 million people might have died prematurely. Largest treatment gaps in low-income countries - Africa (432000 people conservative model). Worldwide use of RRT is projected to more than double to 5.439 million people by 2030

Answer 4

Acute illness - evident. Recognised - locally. Treatment (easily) available. Shortterm, reversible. Low need for follow up. Well researched, managed, surveilled. Acute morbidity high, mortality high. Chronic illness - obscure. Recognised - distant (takes more steps up the line to be diagnosed). Treatment available. Long term, irreversible. Follow up crucial, Poorly researched, managed, surveilled. Acute morbidity low, mortality low. (Chronic diseases therefore attracts less funding). The double burden of disease: infections diseases <-> non-communicable disease (Lack of drugs, specialists and awareness to treat NCDs)

Answer 5

850 million people are estimated to have CKD in the world. 13% of adults in sub-Saharan Africa have some form of kidney disease. 90% of adults living with CKD do not know they have it. USD 84 billion was spent on healthcare for people with CKD in 2017.

Answer 6

Susceptibilities: decreased nephrons, genetics, pregnancy, comorbidities (HTN, DM, HIV, Sickle). Exposures: repeated subclinical injury. Endemic infections (Leptospirosis, Schistosomiasis, Leishmaniasis, Malaria, Hantavirus, Tuberculosis, SARS-CoV-2), repeated AKI episodes. Nephrotoxins (endogenous (myoglobin, haemoglobin), exogenous (allopathic and traditional medicines, environmental exposures), heat stress, dehydration and hypovolaemia)

Answer 7

One in ten people have CKD worldwide. Up to 70% of ESKD reside in LMIC. All current eGFR equations have limited regional validation. These equations may be inaccurate in some instances. Delayed development of prevention and treatment strategies.

Answer 8

Abnormalities in kidney structure and function, present for >3 months with decreased GFR (GFR<60) and/or markers of kidney damage. New eGFR equations that incorporate creatinine AND cystatin C but omit race are more accurate and led to smaller differences between Black participants and non-Black participants than new equations without race with either creatinine or cystatin C alone.

Answer 9

urine protein dipstick, urine albumin/protein, GFR/creatinine/cystatin C. POC ultrasound. Urine protein dip: measures the presence of all proteins, including albumin. Graded as negative, trace or positive. While it is common, cheap and accessible, it is inferior to Albumin Creatinine Ratio (ACR). It can only be used for screening and not diagnosis.

Answer 10

Hypertension, pruritus, nocturia, restless legs, haematuria, dyspnoea, lethargy, vomiting, body swelling, anorexia

Answer 11

CKD in itself is not a primary diagnosis. Attempts should be made to identify the underlying cause. Ain Uganda this may include HIV, FBC, urine dipstick, urine sedimentation, lipid profile, HbA1c, EUC/LFTs, abdominal ultrasound scan (BPH, polycystic), ESR, ANA, cystatin C, serum calcium, phosphorous, albumin, vitamin D, parathyroid hormone, irone studies, kidney biopsy, CT scan

Answer 12

Kidney disease occurs in 10% of adults. It is associated with high mortality. LICs have unique CKD risk factors. The eGFR equations may be poor in LICs. Cystatin C is good marker for CKD in native Africans. Determining CKD requires blood and urine examinations. Early screening and detection is key.

Answer 13

An individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. - WHO. Successful chronic disease management = improvement/minimisation of deterioration QoL. Calman gap - the difference between reality and hopes/aspirations

Answer 14

14 Nephrologists for 45 million population, dialysis support staff 49 nurses, 10 technicians, HD costs 104GBP/month (average income 90GBP/month). 13th leading cause of death, RF: female, >30, higher SES, BMI>25. Three care options: 1 Kidney transplant (almost available - 5 performed so far, live family donation only, costs GBP40,000 initially then GBP400 monthly for life. 1 in 5 allografts fail at 12 months, RF AKI post discharge and surgery >3.5h). 2 Haemodialysis (only available in 4 districts, twice weekly, costs GBP400 to start and GBP25 per week. Lots of complications; CLABSI, only 10% have a fistula). Anaemia is a proxy for overall management, the lower the Hb the lower the likelihood of treatment effect) or 3 Supportive care (Holistic management: physical, psychological, social and spiritual, improved quality of life

Answer 15

Kidney disease is a silent killer in LMIC. Awareness, affordability and accessibility limit utilisation and growth of services. Prevention practices need to be enhanced. Renal supportive care can mitigate suffering.

Answer 16

Burden of AKD is high, causes: Sepsis and hypoperfusion 87% (gastroenteritis, TB, malaria - preventable and treatable), nephrotoxins 3%, obstruction 5%, parenchymal kidney disease 3%

Answer 17

Common, patients are young, often severe, most commonly caused by infections and hypoperfusion, preventable and treatable, outcomes are poor, opportunity to 'save young lives'. Challenges: Not many nephrologists, lack of kidney training for HCPs, inability to measure serum creatinine, infrastructure (including electronic health records) for patient follow up

Answer 18

1 Risk assessment (tool kits, active surveillance), 2 Recognition (clinical [vomiting, low oral intake, weakness, oliguria reported by patient, hypotension, appetite loss, swelling], point of care testing [capillary creatinine at the bedside]), 3 Response (interventions: fluids./ medications, regional stations), 4 Renal support (implementation of PD, telemedicine for coordination, transfer to regional centres for critical cases), 5 Rehabilitation (follow up post AKI, a local level, point of care testing, guidance via telemedicine) - study in Malawi detected that 40% of patients with presumed AKD, actually had previously undiagnosed CKD

Answer 19

Simple: no machines/water plant. Effective: as effective as HD (no evidence for benefit of one modality over another). Affordable: cf establishing HD unit (commercial PD fluids expensive, but can be locally prepared). Can be done in all ages (inc neonates).

Answer 20

AKD is common in LMICs with poor outcomes in historical cohorts. Most cases are treatable with relatively simple means. The KCN proposes a novel approach to AKD management in LMICs. This approach is feasible and effective. Follow-up after AKD episode is essential as opportunities for CKD may be otherwise be missed. Acute PD is a good option for KRT in LMICs.

Answer 21

A biopsy-diagnosis - limited to Black patients (APOL-1). Collapsing FSGS, microcystic dilatation of tubules, tubuloreticular inclusion bodies. CD4 not a good discriminator. A disappearing lesion?

Answer 22

Robert Mugabe's wife dialysis dependent, 1988 set up unit, used piped water - all patients died. 1998 vice president needed dialysis - it has been free of charge at the point of delivery ever since

Answer 23

Age <50, BMI <30, HIV neg, HBV neg, no major comorbidities, potentially transplantable

Answer 24

Patients with ESKD, suffering, with no access to renal replacement therapy - why - cost, distance, social injustice. Kidney disease is neglected at a time when it is increasing in incidence/prevalence and severity. You will encounter it. The golden triad - politically unpopular practically challenging, clinically essential. Vital if we are to turn the tide against NCD.

Answer 25

Global mental health is the international perspective on different aspects of mental health. It is 'the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide'. 'No health without mental health'. All countries are resource limited when it comes to mental health, - the waiting time on the NHS is very long. Look at suicide in HIC vs LMIC - how to address the care gap - how to make use of resources that are available within communities.

Answer 26

Most people, up to 90% of those with mental health problems in some settings, do not receive interventions or services. Treatment gap versus care gap (limitations of 'treatment gap' concept = medicalisation of problems. Does not take quality of service provision and effectiveness into account). Even in countries with high mental health literacy, interdisciplinary teams, empowerment of people with mental health problems, community based case and universal mental health care, there are large care gaps.

Answer 27

Use non-professionals who are trained in the delivery of evidence-based interventions. Friendship bench. Task-shifting

Answer 28

A patient's empowering training targeted at 1 information transfer (symptomatology of the disturbance, causes, treatment concepts) 2 emotional discharge (promote verbalisation of feelings) 3 Support of medication or psychotherapy treatment (adherence) 4 Assistance to self-help. Empathy to make people feel heard and understood

Answer 29

Settings which are the most frequently accessed gateway to healthcare. In most countries, equivalent to primary health care but also include other health care platforms for specific groups such as maternal and child health, HIV/AIDS and other chronic conditions. Platforms of care = where intervention is delivered (population, community, health care platforms). Platforms = location, delivery channels = means of delivery (eg for the health care platform it would be self-management and care, primary health care, and hospital care)

Answer 30

Families, lay counsellors, cross-sector providers, mental health specialist teams, primary care teams all have a role in patients/people with lived experience. Healing begins when people start sharing their stories.

Answer 31

Specific intervention packages for specific disorders. Package of care: 1 Brief psychological interventions (psychoeducation, structured psychological interventions) 2 Medication 3 Social interventions (eg social skills training to increase social functioning)). Stepped care aims to treat patients with an adequate treatment of the lowest possible intensity while continuously monitoring progress. Stepped care is usually combined with collaborative care, which aims to systematically integrate different care providers. Empathy = healing through understanding

Answer 32

A multi-professional approach to patient care. A case manager (a named person who coordinates or delivers care), a structured management plan (who does what, what kind of interventions will be provided by whom?), Scheduled patient follow ups, Enhanced interprofessional communication. How to narrow the care gap to provide the most care to the most people.

Answer 33

Train trainers -> train grandmothers - > allocate park benches -> support groups. Connecting people, but still need a healthy dose of science to ensure these are effective. Grandmothers working on Friendship Bench had lower rates of PTSD and common mental disorders. The grandmothers attributed the resilience to a sense of purpose and belonging. Intergenerational connectedness. Lessons learnt: 1 You can't follow up everyone you see. 2 Triangulation of data is costly 3 The qualitative narrative is important/hope 4 Need to leverage digital technology more

Answer 34

80% of men and 60% of women in developed countries drink at some time during their lives. Men>Women exact ratios. Largest burden 25-50yo, followed by a gradual decline. Alcohol and drug use is the fifth leading risk for poor health in men. 2.8 million deaths were attributed to alcohol use, 6.8% of deaths among males. 7th leading risk factor for premature death and disability. Largest contributor to premature mortality amongst all mental and substance use disorders. DALYs associated with alcohol-attributable burden: Unintentional injuries 30% intentional injuries 9.5% Alcohol use disorders 13.9%, Infectious diseases 11.2%. 40 ICD-10 categories, component cause for more than 200 disease and injury conditions. Impacts on psychological, family, legal and workplace. Societal costs extend beyond healthcare costs, and include social harm, loss of productivity and direct law enforcement costs.

Answer 35

1 Hazardous: when a person drinks in a way which can lead to some physical, mental or social harm in future. 2 Harmful drinking: when a person drinks in a way which has started causing some physical mental or social harm. 3 Dependent drinking: most severe form of drinking alcohol. Most of the people in this category drink daily and sometimes even in morning. In addition to this alcohol starts affecting many areas of their life like health, family, job in significant way. Patterns of drinking are important - episodic heavy drinking is much higher risk

Answer 36

Socioeconomic context and position (alcohol production, distribution, regulation. Health and welfare systems). Differential vulnerability (Gender, age, poverty marginalisation). Differential exposure (drinking environment, drinking culture, alcohol quality). Alcohol consumption (volume, pattern). Health outcome (chronic conditions, acute conditions). Socioeconomic consequences (loss of earnings, unemployment. Stigma. Barriers to accessing health care.)

Answer 37

English-speaking and Nordic societies over the last 50 years. Alcohol more available in general, and to the poor in particular. Rates of alcohol problems have climbed, particularly for those of lower socioeconomic status.

Answer 38

Lower levels of per capita alcohol consumption, high levels of abstention by adult males, and consequently an overall lower burden of alcohol-attributable disease. Patterns in some cultures gear drinkers towards consuming alcohol hazardously. Central Asia and eastern Europe - highest rates of alcohol consumption, along with a disproportionately high burden of alcohol-attributable harm. Inequitable impact on the poor.

Answer 39

Vulnerability to alcohol related harm differs across social grouping. Cumulative disadvantage. Intergenerational transfer of risk. People in LMIC and in groups of low SES statis in HIC, are often specifically targeted by alcohol advertisers and distributors. Alcohol-related health and social problems are disproportionately high in those LIC communities that are heavily exposed to alcohol advertising and that have a high density of alcohol sales outlets.

Answer 40

The 'package' of psychoeducation, structured psychological treatments, medication and social interventions

Answer 41

Stigma, low recognition, not recognised as clinical syndromes. Recognised only as biological syndromes. Not enough time and competing priorities of existing healthcare workers. Not enough skills for delivery. Low adherence with treatment. Treatment gap is huge, There is only 10% of those with harmful drinking that access care.

Answer 42

Substantial burden, harm results from pattern of drinking, impact on several domains, barriers to accessing treatment.

Answer 43

Alcohol price and taxes*. Restricting access to retail sale of alcohol*. Regulation of the drinking context. Restriction on alcohol advertising/marketing*. Drink-driving countermeasures. Community mobilisation. Education. The stars reflect the top three for impact.

Answer 44

Screening, brief intervention, referral for treatment

Answer 45

Conversation with an individual about their alcohol use. Short 5-10min, evidence based >1 in 8 success rate. Structured (stages/steps), non-confrontational style. Seeks to motivate and support the person to think about and/or plan alcohol behaviour change. Not a school of psychotherapy. Approach: 1 Establish rapport 2 elicit thoughts - provide feedback 3 enhance motivation 4 negotiate a plan - moderate quality evidence.

Answer 46

Timely intervention = better outcomes. Type of help they receive makes little difference in long-term outcomes. Medically-based inpatient treatment not more effective than non-medical residential or outpatient treatment. Little evidence exists that any one psychotherapy or pharmacological approach is best. Less intensive treatments are as effective as the more intensive options.

Answer 47

Benzodiazepines for treating alcohol withdrawal. Disulfiram might help prevent relapse in compliant patients but is ineffective at promoting continuous abstinence. Naltrexone, acamprosate, topiramate, and baclofen have modest effects

Answer 48

Communities that care 'CTC": Community coalitions. Coordinate activities and resources to prevent adolescent substance use and delinquent behaviour. Mobilise communities in prevention and health promotion initiatives. Identify risk factors and protective factors experienced by this group. Effective prevention and early intervention programmes to address them.

Answer 49

Better than other well-established treatments in facilitating continuous abstinence and remission. At least as effective as other well established treatments in reducing intensity of drinking, alcohol-related consequences and severity of alcohol addition. Reduces healthcare costs substantially more than other types of treatments.

Answer 50

Accessibility, social support, cultural relevance, sustainability, costs, holistic

Answer 51

Action, everybody's business, evidence-based & context relevant (needs to be culturally appropriate), platform integration, social determinants, prevention, policies

Answer 52

A range of intervention options. Interventions need to be mapped on to profile of drinking problems. Innovative solutions needed for low resource settings. 'What works' versus 'How to make it work'

Answer 53

Corynebacterium diphtheriae. Aerobic Gram-positive rod-shaped bacteria - pleomorphic, metachromatic polar granules. Primarily causes URTI, cutaneous infection. Transmitted by droplets, secretions and fomites. Without Abx communicable for 2-6w, with effective Abx communicable for 48h. Incubation 2-5d.

Answer 54

Primarily exotoxin mediated disease. Death of mucosal epithelial cells (releases grey fibrinous pseudomembrane which bleeds on contact). Adjacent tissue becomes inflamed and oedematous. Gross lymphadenopathy. Respiratory failure due to airway obstruction or aspiration of pseudomembrane. Lymphatic and haematogenous toxin spread (myocarditis 2-7w, neuropathy & paralysis 1-3m, renal failure, disseminated disease, shock, multi-organ involvement)

Answer 55

Well controlled by vaccination (antitoxin vaccination)

Answer 56

Laryngitis, pharyngitis or tonsillitis AND adherent membrane of the tonsils, pharynx and/or nose or gross lymphadenopathy.

Answer 57

Catarrhal (erythema of pharynx, no membrane) > Follicular (patches of exudates over pharynx and tonsils) > Spreading (membrane is formed covering the tonsil and post pharynx) > Combined (More than one anatomical site involved eg throat and skin)

Answer 58

Confluent sharply demarcated, tightly adherent and dark grey (initially isolated spots of grey or white exudate in tonsillar and pharyngeal area, spots coalesce within a day to form pseudomembrane that becomes progressively thicker). Extends beyond margins of tonsils into tonsillar pillars, palate and uvula (Streptococcal infection: white membrane limited to tonsillar area). Dislodging of membrane likely to cause bleeding. Five possible areas to examine - although almost impossible to examine nasopharynx (1 & 2 tonsil, 3 uvula, 4 oropharynx, 5 nasopharynx). Simple - one area only, Extensive - two or more areas)

Answer 59

During outbreak, routine throat swabs are not recommended. Prolonged difficulty with access to microbiology testing: First 17 throat swabs from MSF: 2 were diphtheria PCR positive. Subsequent 185 clinical diphtheria cases assessed 58 (31.4%) PCR positive

Answer 60

1 Isolate patient immediately and apply standard and contact precautions when caring for the patient. 2 Administer diphtheria antitoxin (DAT) as soon as possible if in field hospital. 3 Administer antibiotics (penicillin or erythromycin) following DAT as soon as possible. 4 Monitor closely and provide supportive therapy for severe complications (ie airway management, cardiac, neurologic and renal failure). 5 Vaccinate. In patients with suspected or confirmed diphtheria, WHO recommends using macrolide antibiotics (azithromycin, erythromycin) in preference to penicillin antibiotics

Answer 61

Triage and admission areas, National and international staff, Careful attention to IPC between clean and dirty zones, space between beds, specific areas for DAT administration

Answer 62

Equine serum product since 1890s. Pre-DAT mortality 50%. Controlled trial mortality no DAT 12.2% vs DAT 3.3%. Most effective if given early. Risks: anaphylaxis (<1%), febrile reaction s(4%), serum sickness (9%). Sensitivity test for all candidate patients. Only give in sites with sufficient staff and ability to monitor. Can be given to pregnant and breastfeeding women. Dose by disease severity not size of patient. Additional considerations: Global DAT are limited, there were several concurrent diphtheria outbreaks worldwide (Yemen, Haiti, Venezuela, Indonesia). Manufacture takes ~6 weeks. Consent and cultural sensitisation (who makes the decision and how quickly for children? Some patients will have sensitisation test reactions. Some patients may receive DAT and die)

Answer 63

Indications: tonsillar diphtheria/adherent plaques (initially only <5y, then all ages), pseudomembrane, shock and symptomatic signs). All given on monitor with access to resus and anaphylaxis treatment. Test dose as per protocol. At sites with adequate staffing. Different doses depending on the signs. Do not consider in >7d symptoms, unresponsive, airway compromised and non-salvageable, shock resistant to appropriate treatment. Sensitisation testing (skin) was poorly predictive of adverse reactions, so routine sensitivity testing no longer recommended prior to administration of diphtheria anti-toxin.

Answer 64

NCDs account for 70% of all deaths worldwide and causing half of all global disability. But only 1% of health funding addresses NCDs. Cancer is currently responsible for 1 in 6 deaths globally. 17 million new cases of cancer a year. 9.6 million deaths globally from cancer. The majority of these deaths (65%) are in LMICs. Increasing incidence is outpacing improved cancer survival. Start with the basics: 1 Prevention 2 Early detection (advanced stage at presentation, more prevalent in LMICs) 3 Access to a system with capacity and capability - palliative care 4 Advocacy. Evidence based accessible quality cancer care of value across the continuum for all irrespective of geography or income level. Those with lived experience. Science (biology, pharmacology, sociology, implementation science, epidemiology, medical MDT:oncology, histopathology, surgery, radiology, psychologist), policy, humanities/social science (theology, philosophy, mythology, popular culture, anthropology, economics, geopolitics, psychology, sociology (human rights, women's rights)), advocacy, civil society, corporates

Answer 65

Causes: poor leadership, the market/economy, non-anthropogenic (outside our control) and the unknown. Results: pandemics, conflict (biological, cyber, nuclear, nanotechnology), artificial intelligence, earth system governance (loss of biodiversity, climate change, non-equitable resource distribution, overpopulation, non-sustainable agriculture)

Answer 66

Conflict shatters health systems.89 million people worldwide forcibly displaced (2022). 83% of these are hosted by LMICs. Millions of stateless people. 1 in 88 people on earth has been forced to flee. Effect on conflict on cancer management: interrupts supply chains eg medications, mass migration of people including manpower, loss of family support, loss of infrastructure, transportation (power, hospitals damaged). Conflict leads to: increases cancer risk, delays in diagnosis, prevents treatment, worsens outcomes.

Answer 67

A health inequality is a difference in health or healthcare that people experience and is not necessarily unfair or unjust. A health inequity is an unnecessary, avoidable, unfair and unjust difference between the health or healthcare of one person and that of another

Answer 68

Context is essential: life expectancy, role of infection in causing cancer, epidemiological transitions (NCDs coexisting with high levels of communicable diseases). Health system in that particular country - access to care, infrastructure, manpower. The wealth of the individual, conflict, cancer literacy, culture/beliefs/religion.

Answer 69

Increasing incidence: aging, change in lifestyle factors (obesity), change in reproductive behaviour, population growth, declines in infection related disease, rising awareness

Answer 70

NCDs cost world economy $47 trillion. Macro (economic cost of cancer is 4-12% of GDP, economic cost of cancer 2020-2050 will be 25.2 trillion. 5% of global spending on cancer goes towards LMICs). Micro (consideration to direct and indirect costs. Out of pocket payments for NCD treatment and care cause household poverty and catastrophic expenditure. Disability, premature death, disruption of family life, loss of the national economy - exacerbating the cycle of poverty). HEALTH IS AN INVESTMENT NOT A COST

Answer 71

There is an intensifying debt crisis for poorest nations' - World Bank. $9 trillion owed by LMICs. Exacerbates/causes poverty which affects other development agenda priorities eg education and health

Answer 72

Translate the evidence to policy. Nearly 80% worlds billion smokers live in LMICs. WHO Framework Convention on Tobacco Control (protect public health policies from commercial interests of tobacco industry, taxation, protect people from exposure to tobacco products, regulate tobacco product disclosures, regulate packaging, warn people about the dangers of tobacco. Ban tobacco advertising, promotion and sponsorship. Offer people help to end their addiction to tobacco. Control the illicit trade in tobacco products. Ban sales to and by minors. Support economically viable alternatives to tobacco growing)

Answer 73

Epidemiological transition - double/triple burden of disease. Virus-driven cancers - HIV, HCC, HPV, EBV, HHV8. 25-30% of all cancers in Africa are linked to infection (viruses, bacteria, parasites). 2 of the 3 top causes of cancer death in Africa (CaCx and liver cancer) are associated with infectious agents

Answer 74

69% of people infected globally with HIV live in Africa. HIV leads to an increased chance of developing malignancy. Seen early in the epidemic when Kaposi sarcoma (KS) and non-Hodgkin Lymphoma (NHL) and cervical cancer were named AIDS-defining illnesses. ART (post 1996) has changed this and now non-AIDS defining cancers are a major contributing factor. These include head and neck cancers, anal cancer, lung cancer, liver cancer, Hodgkin lymphoma, skin cancer (all types), testicular cancer. Cohort of 42,000 HIV+ patients with uninfected matched controls - cancer incidence RR 2.4 for unsuppressed, RR 2.0 early suppression and RR 1.52 for longterm suppression. Cancers present at younger ages in HIV+ people. Why does HIV cause cancer? Pathogenesis is complex - HIV infection may directly affect a number of cellular processes that lead to cancer (activation of proto-oncogenes, alteration in cell cycle regulation, inhibition of tumour suppressor genes, other genetic alterations leading to oncogenesis)

Answer 75

99% of CaCx is caused by infection with HPV. HPV 16/18 most common oncogenic subtypes. Most infections with HPV resolve spontaneously and cause no symptoms, chronic infection can cause CaCx in women. Fourth commonest cancer in women (in 2018 an estimated 570,000 women globally were diagnosed and 311,000 women died from it). In some countries (most in SSA), CaCx is the leading cause of female cancer death. When diagnosed it is one of the most successfully treatable forms of cancer as long as its detected early and managed effectively. In the late stages it can be managed will palliative treatments. May 2018 WHO launched the eradicate CaCx campaign. 3 key pillars with targets: 1 Vaccination 90% of girls fully vaccinated with the HPV vaccine by age 15. 2 Screening 70% of women screening using a high-performance test by age 35 and again by age 45. 3. Treatment:90% of women with pre-cancer treated and 90% of women with invasive cancer managed

Answer 76

345 million people worldwide live with HBV or HCV, for most testing and treatment is beyond reach. Chronic HBV (50%) or HCV (20%) is associated with HCC. Sixth most prevalent cancer worldwide (780,000 cases in 2018). HBV, HCV, HDV are responsible for >95% hepatitis deaths. M:F 3:1. Vaccination against HBV can prevent infections. This with testing, medicines and education could prevent 4.5 million premature deaths in LMICs. Antiviral therapy given to people with chronic HBV or HCV reduces risk of HCC. WHO elimination plan by 2030: Reduce new infections of HBV and HCV by 90% reduce hepatitis related deaths from liver cirrhosis and cancer by 65%, Ensure that at least 90% of people with HBV and HCV are diagnosed. At least 80% of those eligible receive appropriate treatment

Answer 77

Highly aggressive B cell NHL (characterised by the translocation and deregulation of the MYC gene on chromosome 8). 3 types 1 Endemic (African - found in Africa and New Guinea, peak incidence 4-7 years old, twice as common in boys, 3-6 cases/100,000 children (accounts for 30-50% of childhood cancers in equatorial Africa)) 2 Sporadic (non-endemic - found in USA and Western Europe, 3 cases/million adults and children, peak incidence 11 years old, 3-4 times commoner in boys) 3 Immunodeficiency associated (seen mainly in people with HIV, not decreased in incidence with HAART, occurs with CD4 count is high). NHL is the 4th commonest cause of cancer mortality in Africa. EBV, HIV and HVC implicated: chronic EBV plays a part in all Endemic BL, and a minority of the other two types. Aggressive presentation with tumour doubling time of 25 hours

Answer 78

Four epidemiological forms of KS all related to HHV-8. 1 AIDS-related or epidemic KS, (AIDS defining illness; over 20,000 times more common in HIV+ people compared to general population, more common in homosexual or bisexual men, related to low CD4 count, pre widespread use of HAART the 10-year probability of developing KS if you have HIV and HHV-8 was approximately 50%) 2 Endemic or African KS (was endemic to parts of Africa), 3 Organ transplant associated (from chronic immunosuppression/transmission from the transplant) 4 Classic (indolent disease seen in older men of Mediterranean and Jewish). Can occur anywhere in the body - cutaneous disease is the most common

Answer 79

Bladder cancers are the most common genitourinary malignancy in men and women. Schistosomiasis is caused by infection with a blood fluke; parasites live in freshwater snails; cercariae (the infectious part) then contaminate water and penetrate the skin. 7 Schistosome species; Schistosoma haematobium implicated in bladder cancer. Schistosomiasis is associated with all subtypes of bladder cancers and affects about 200 million people globally. Most prevalent areas East Africa and Middle East, where bladder cancer is the most prevalent cancer in men and the second most prevalent in women. Median age presentation in 40s. M:F 5:1 (agricultural work). Leads to a calcified bladder. Localised/locally advanced disease usually requires radical cystectomy with lymph node dissection.

Answer 80

For every US$1 spent on promoting healthy eating, US$500 is spent on promoting processed unhealthy foods. Much published data linking obesity to increased risk of breast cancer and worse outcomes

Answer 81

A risk factor for many cancers including: oral cavity, pharynx, larynx, oesophagus, liver, colorectal and breast. In 2016, alcohol attributable cancers were responsible for 400,000 deaths worldwide. Carcinogenic through genotoxic effects of acetaldehyde, increased oestrogen concentration, as a solvent for tobacco carcinogens, production of reactive oxygen species and nitrogen species, changes in folate metabolism

Answer 82

Estimated that outside air pollution contributed to 4.2 million premature deaths of which 6.2% were from lung cancer. Estimated that 4 million people die prematurely each year from exposure to household air pollution from cooking with solid fuels and kerosene

Answer 83

Protects against luminal and triple-negative breast cancer. Lactational induced amenorrhoea-reduction in time exposed to sex hormones. Permanent alteration in breast histology characterised by involution of terminal duct lobular units

Answer 84

Advanced stage at presentation more prevalent in LMICs (50-80%). Metastatic breast cancer - worse outcome, more expensive to treat

Answer 85

1 Histopathology (biopsy - most economic diagnostic method, quality assurance, receptor testing often not available, training/collaboration where possible, innovative delivery (implementation of national telepathology platforms). 2 Radiology (appropriate tool for the appropriate situation) 3 Surgery (Less than 25% of patients worldwide get access to safe, affordable or timely surgery. Of the estimated 15.2 million new cancer cases in 2015 >80% will require surgery. May 2015 WHO adopted a resolution to strengthen emergency and essential surgical care as a component of universal health coverage) 4 Radiotherapy (essential for 50% cancer patients)

Answer 86

WHO essential medicines list: 46 cancer drugs. Improving access to medicines: use of generics and biosimilars, compulsory licensing TRIPS (trade related aspects of intellectual property), price discrimination, harness global mechanisms for pricing for financing and drug procurement. Treatment de-escalation also essential - optimising the dose and schedule of drugs for broader equity - more is not always better

Answer 87

1 A cultural shift in the approach to care and support for people affected by cancer to a greater focus on recovery, health and wellbeing after cancer treatment. 2 A shift towards holistic assessment, information a provision and personalised care plan. This is a shift from a one size fits all approach to follow up to a personalised care planning based on assessment of individual risks, needs and preferences. 3 A shift towards support for self-management. This is a shift from a clinically led approach and follow-up care to supported self-management, based on individual needs and preferences. This approach empowers individuals to take on responsibility for their condition supported by the appropriate clinical assessment, support and treatment. A shift from a single model of clinical follow-up to tailored support that enables early recognition of the consequences of treatment and the signs and symptoms of further disease as well as tailored support for those with advance disease. 5. A shift from an emphasis on measuring clinical activity to a new emphasis on measuring experience and outcomes for cancer survivors through routine use of patient-reported outcome measures in aftercare services.

Answer 88

Reduce burden of patients presenting with advanced-stage disease. Improve access, affordability and outcomes in cancer care via solution-orientated research. Emphasize country-level health economic assessment of cancer interventions and technologies, health financing mechanisms and value-based care. Scale up quality implementation research in cancer control. Leverage technology to improve cancer control supported by robust scientific evidence.

Answer 89

Mutual respect, relationships take time to build. Reciprocal learning. Sustainability. Coordination. Systems strengthening.

Answer 90

Cancer is a major cause of morbidity and mortality globally. The need to harness political will: Create a context sensitive narrative with hope. Involve all stakeholders in policy solutions. Funding: investment not cost. Cancer preparedness: NCCPs, intelligence, integration within an accessible health system. Focus on prevention, early presentation, timely diagnosis and treatment. Align with the SDGs eg universal health care. Common sense oncology. "Health cannot be a question of income: it is a fundamental human right" "Shooting for the moon is important, but so is shooting for a world that is just and equitable"

Answer 91

"Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment of pain and other problems, physical, psychosocial and spiritual" -WHO 2002 Of the 56.8 million people worldwide who need palliative care, 39% CV disease, 34% cancer, 10% Chronic lung disease, 6% HIV/AIDS, 5% Diabetes. Barriers to access of opioids has significant impact upon provision of palliative care in LMIC. Education builds capacity and sustainability. Palliative care is everyone's responsibility. Can be a low-cost, high impact intervention. Those with palliative care needs are some of the most hidden and vulnerable. Future proof palliative care.

Answer 92

Policy (Palliative care needs to be part of the national health plan. National standards defining how programmes must operate. Adequate funding. Appropriate service delivery). Education (Part of the curriculum for HCWs, higher qualifications, training and support for families/caregivers, public advocacy) Medicines (Access to essential medicines, prescribers, reliable distribution, low cost dispensing). Implementation (manpower, strategic planning, infrastructure/health systems strengthening, integration for sustainability). Also need additional human factors

Answer 93

Training -> Community needs assessment -> needs-based service planning -> identify patients in need for PC -> provide care at home under professional supervision -> follow up on patient's and carers' needs and wellbeing -> fundraising -> awareness and educational activities to create compassionate communities -> coordination and administration of neighbourhood networks in palliative care services. At the centre of this is community, patient and their carer