1
Q
What factors feed in to an evidence-based decision? (4)
A
- evidence from research
- patient preferences
- clinical expertise
- available resources
2
Q
Why do we need evidence based medicine?
A
- increasing medical knowledge
- limited time for clinicians to read
- inadequacy of “traditional” sources of information (e.g. textbooks are out of date as soon as they are published)
- disparity between:
(1) diagnostic skills and clinical judgement - which increase over time
(2) up-to-date knowledge and clinical performance - which tend to decrease over time
3
Q
What is evidence-based medicine?
A
The process of identifying and using the most up-to-date and relevant evidence to inform decisions for individual patient problems
4
Q
Outline the 5-step process of evidence-based medicine:
A
1) Converting the need for information into an answerable question (PICO)
2) Identifying the best evidence to answer that question
3) Critically appraising the evidence for its validity, impact and applicability
4) Integrating the critical appraisal with clinical expertise and the patient’s unique circumstances
5) Evaluating our effectiveness and efficiency in carrying out in steps 1-4, and seeking ways to improve them
5
Q
What are the four essential components of a foreground question?
A
P - Patient / Problem
I - Intervention
C - Comparison Intervention (if relevant)
O - Clinical Outcome(s)
E.g. In younger women with breast cancer, is mastectomy with chemotherapy more effective than mastectomy alone, in reducing the risk of cancer recurrence?
6
Q
What is the aim of a background question?
A
Seek general knowledge about a disorder
7
Q
What is the aim of a foreground question?
A
Seek specific knowledge about managing patients with a disorder
8
Q
What are the two essential components of a background question?
A
1) A question root: who, what, where, when…
2) A disorder or an aspect of a disorder
e.g. What causes breast cancer?
9
Q
How does need for background and foreground questions vary over time?
A
- depends on expertise
- more background questions when less experienced with the condition
- more foreground questions when more experienced with the condition
10
Q
What are the 5 components of the chain of infection?
A
- infectious agent
- reservoir/environment
- mode of transmission
- portal of entry
- host
11
Q
What characteristics of the infectious agent influence who gets infected, how and why?
A
- ability to reproduce
- survival
- ability to spread
- infectivity
- pathogenicity
12
Q
Describe modes of infection transmission:
A
Respiratory:
- droplet
- airborne
- aerosolisation of water
Ingestion:
- consumption
- hand-to-mouth (person to person, or environment or person)
Blood borne
Sexual
13
Q
What characteristics of potential hosts influence who gets infected, how and why?
A
- chronic illness
- nutrition
- age (extremes)
- immunity (lack of)
- lifestyle factors (drugs, alcohol, sex, occupation, deprivation, physical activity etc)
14
Q
What is the motivation for global health?
A
- Increased awareness of global health disparities
- Enthusiasm to make a difference across borders
15
Q
What is the 10/90 gap?
A
10% of global healthcare resources are allocated to 90% of the global population
16
Q
What are the key words associated with the definition of global health?
A
- health of the global population
- equity
- interdependence
- transnational
- emphasis on wider determinants of health
- interdisciplinary / cross-sector working
- prevention AND care
17
Q
Give 5 global issues that affect health globally:
A
- global warming
- development, poverty, and inequality
- food and water security
- wars and security threats
- migration
18
Q
What are the major functions of global health?
A
- provide health-related public goods (e.g. research, guidelines)
- manage cross-national externalities through epidemiological surveillance, information sharing and coordination
- mobilise global solidarity for populations facing deprivation and disasters
- convene stakeholders to reach consensus on key issues (setting priorities, negotiating rules, facilitating mutual accountability, advocating for health in other policy-making arenas)
19
Q
Why do we have innate immunity?
A
- prevent pathogen establishment
- limit pathogen multiplication
- provide protection from early death during expansion of acquired immune response
- broad specificity
- helps direct and shape the acquired immune response
20
Q
How might pathogens avoid complement activation?
A
- surface structure
- regulatory proteins
21
Q
How might pathogens avoid phagocytosis?
A
- capsules
- anti-phagocytic ‘toxins’
22
Q
How might pathogens evade host defences?
A
- avoid complement activation
- avoid phagocytosis
- inhibit host cell signalling pathways
- resist or evade phagocyte killing mechanisms
23
Q
What is the goal of active immunisation?
A
Induce a state of immunological readiness such that a first infection with a given pathogen is recognised as though it were the second infection
24
Q
What is the goal of passive immunisation?
A
Transfer preformed immunological mediators into a normal individual to generate a state of enhance immunity
25
Give 3 types of passive vaccination:
- specific antibody transfer
- transfer of normal serum gammaglobulins
- maternal antibodies (placental IgG, colostral IgA)
26
What are the different types of active vaccines?
Live:
- natural attenuated (related strain or species e.g. smallpox and cowpox)
- artificially attenuated (e.g. MMR)
Non-living:
- killed whole organisms (e.g. typhoid)
- antigenic components of the organism (e.g. HepB)
- DNA from the organism (none licensed yet)
27
Why was the eradication of smallpox possible? (4)
- exclusive to humans
- no hidden carriers
- single serotype
- vaccination 100% successful
28
What is bad news?
Any news that drastically and negatively alters the patient's view of their future
29
Give examples of psychosocial context that might mean something is bad news for one person but not for another:
- Social life, e.g. teen diagnosed T1D
- Employment, e.g. surgeon who develops Parkinson's tremor
- Finance, self-employed and needing time off work for treatment
- Social, e.g. mother with acute pain who is alone looking after young children
30
Why might breaking bad news be difficult?
- institutionalised beliefs
- personality types
- personal experience
- gender
- culture
- religion
- relatives of the patient
31
Why might clinicians avoid giving bad news?
- uncertainty of patient expectation
- fear of destroying hope
- fear of inadequacy
- not feeling prepared to manage the patient's response
- embarrassment due to having previously given too optimistic a view to the patient
32
What distancing strategies might clinicians use when they are reluctant to deliver bad news?
- avoidance
- normalisation
- premature reassurance
- false reassurance
- switching
- jollying along
33
What is the ABDCE model for delivering bad news?
```
A - Advance preparation
B - Build a relationhip
C - Communicate well
D - Deal with patient reactions
E - Encourage and validate emotions
```
34
What is the SPIKES model for delivering bad news?
```
S - Setting up
P - Perception
I - Invitation
K - Knowledge
E - Emotions
S - Strategy and Summary
```
35
How might you prepare to break bad news?
- find the right setting
- involve significant others
- find out how much the patient knows
- find out how much the patient wants to know
36
Outline the grief response:
- numbness for up to 2 weeks
- distress and acute grief for 6 months
- period of adjustment for 6 - 12 months
37
How might patients respond to bad news?
- no response
- grief
- anger
- relief (technically probably not bad news but clinician thought it would be)
38
Most commonly diagnosed cancers worldwide?
Lung, Breast, Bowel, Prostate, Stomach
39
Most commonly diagnosed cancers in the UK?
Breast, Prostate, Lung, Bowel, Melanoma
40
Most common cancers in females in the UK?
Breast, Lung, Bowel, Uterus, Melanoma, Ovarian
41
Most common cancers in males in the UK?
Prostate, Lung, Bowel, Bladder, Kidney, Non-Hodgkin Lymphoma
42
How do health risks change as a population develops?
Risk shifts from primarily communicable diseases to non-communicable diseases
43
Why do health risks change as a country develops?
- improvements in medical care
- ageing population
- public health interventions (e.g. improved sanitation, vaccination programmes)
44
What percentage of deaths are due to cancer worldwide and in Europe?
14% worldwide
| 20% in Europe
45
Which cancers are responsible for most cancer deaths in the UK?
Lung, Bowel, Breast, Prostate, Pancreas
46
How do childhood cancers differ from adult cancers?
- (usually) diagnosed <14 years
- histopathologically different
- clinically different
- generally more responsive to therapy
- much rarer
47
What are the most common childhood cancers in the UK?
Leukaemias, Brain and CNS tumours, Lymphomas, Sarcomas
48
Which factors can cause cancer?
- Infection
- Radiation
- Occupation
- Hormonal
- Genetics
- Diet
- Alcohol intake
- Smoking
- Obesity
49
Primary prevention aims to...
reduce exposure
50
Secondary prevention aims to...
identify those with pre-clinical disease to influence progression of disease
51
Tertiary prevention aims to...
modify outcomes of the disease
52
What does GMC guidance say about clinical record keeping?
Doctors must keep 'clear, accurate, legible and contemporaneous patient records that report the relevant clinical findings, the decisions made, the information given to patients, and any drugs or treatments prescribed'
53
What are the functions of the clinical record?
- support patient care
- improve future patient care
- social purposed at the request of patients
- medico-legal document
- service planning
54
How does the clinical record support patient care?
- record of prior contact with health care providers
- aide memoire to facilitate communication with and about patients
- makes information available to clinicians in other services who are caring for the same patient
- source of information for inclusion in other documentation e.g. lab requests, referrals etc
- place to store info from other parties +/- organisations
55
How can the clinical record improve future patient care?
- audit
- call and recall programmes to target specific groups
- financial planning
- management
- research
56
What are the medical functions of the clinical record?
- support method and structure of history and examination
- ensure clarity of diagnosis so that anyone reading the record could understand how the diagnosis was reached
- record of treatment plans
- enable comprehensive monitoring
- help to maintain a consistent explanation for the patient
- ensure continuity of care (particularly important for shift-working)
57
What should be recorded in the clinical record?
- presenting symptoms and reasons for seeking care
- relevant clinical findings
- diagnosis and important differentials
- treatment/care options (including safety netting)
- discussion about risks and benefits of care/treatment
- decisions about care/treatment
- action taken and outcomes
58
How should the information be recorded in the notes? (4 key words)
- professionally
- contemporaneously
- comprehensively
- permanently
59
What is in the summary care record?
- name
- address
- DOB
- NHS number
- medication
- allergies
60
What were the conclusions of the Eurocare II report?
Despite limitations in methodology, cancer survival in the UK in the 80s and 90s was one of the worst in Europe
61
What were the consequences of the Eurocare II report?
Expert Advisory Group formed in 1995 - generated the Calman-Hine report
62
What were the main points of the Calman-Hine report?
- all patients should have access to a uniformly high quality of care
- public and professional education should help early recognition of cancer symptoms
- patients, families and carers should be given clear info about treatment options and outcomes
- the development of cancer services should be patient centred
- primary care should be central to cancer care
- psychosocial needs of cancer sufferers and carers must be recognised
- registration of cancer and monitoring of cancer outcomes is essential
63
What were the solutions presented by the Calman-Hine report?
3 Levels of cancer care:
- primary care
- cancer unit for every 250,000 people (treat common cancers, carry out diagnostics, do common surgery, non-complex chemotherapy)
- cancer centres for every million people (treat rare cancers, radiotherapy treatments, complex chemotherapy)
MDT is key
64
What is the structure of a cancer MDT?
```
Core:
- Medics
-- physician
-- surgeon
-- oncologist
-- radiologist
-- histopathologist
- Specialist nurses
- MDT co-ordinator
Extended:
- physio
- dietician
- palliative care
- chaplain
```
65
What is the function of a cancer MDT?
- discuss every new diagnosis of cancer within their site
- decide on a management plan for every patient
- inform primary care of the plan
- designate a key worker for that patient (usually a specialist nurse)
- develop referral, diagnosis and treatment guidelines for their tumour site according to local and national guidelines
- audit
66
What were the aims of the NHS Cancer Plan 2000?
- save more lives
- ensure people with cancer get the right professional support and care as well as the best treatments
- take inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals
- build for the future though investment in the cancer workforce, strong research, and preparation for the genetics revolution - so that the NHS never falls behind in cancer care again
67
Reports / strategies / groups for cancer care?
Late 90s/Early 2000s: Eurocare II
1995: Calman-Hine Report
2000: NHS Cancer Plan*
2007: Cancer reform strategy*
2011: Improving outcomes: A Strategy for Cancer
2015: Independent Cancer Taskforce
68
What were the 6 key areas for action identified in the Cancer Reform Strategy 2007?
1. Prevention
2. Diagnosing cancer earlier (screening)
3. Ensuring better treatment
4. Living with and beyond cancer (e.g. national cancer survivorship initiative)
5. Reducing cancer inequalities
6. Delivering care in the most appropriate setting (locally when possible, centrally when necessary)
69
What influences how we think about a body?
- physical
- environment
- discourses
70
Elias (1982) - The civilised body
- Separation of mind and body
- 3 elements:
- hide natural functions
- control emotions
- separate space between bodies
71
3 interdependent elements of body image and behaviour:
- altered physical appearance
- perception of self, investment in physical attributes
- impact on socialisation
72
White (2000) - Clinically Significant Body Image Problem
- existence of a marked discrepancy between the actual or perceived appearance or function of a discrete bodily attributes, and the individual's expressed ideal
- mediates negative emotional and behavioural consequences
- interferes significantly with normal routine, functioning or relationships
73
What makes a conclusion valid?
It follows logically from the premises
74
What make a conclusion sound?
It follows logically from the premises and the the premises are true
75
What is affirming the consequent fallacy?
- the premises are correct but there is error between the premises and conclusion
- usually the error occurs due to assumption that the premise was a necessary condition, when in fact it was only a sufficient condition (one of many possible conditions) to prove the conclusion
76
What is an ab hominem logical fallacy?
When you don't criticise the quality of the argument a person has made but instead criticise the person themselves
77
What is the straw man logical fallacy?
When you misrepresent the argument that someone has put forward in such a way that is easy to refute the argument
78
What is the logical fallacy often called "begging the question"?
Using circular arguments, the premises of the arguments already assume the conclusion to be true and so on't actually support it
Phase I: H&S
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