1
Q
Explain the need for informed consent
A
- Consent: process of getting permission before conducting a healthcare intervention on a person or for disclosing personal information.
- Obtaining informed consent isn’t always required e.g. if patient lacks capacity (child/mentally ill).
- Consent is an ethical and legal obligation.
- Consent is: situation specific/dynamic, recorded, informed, voluntary, patient must have mental capacity to make the decision.
2
Q
Outline the key aspects of WHO operative checklist
A
- Aims to decrease errors and adverse events and increase teamwork and communication in surgery.
- 19 item checklist.
- Reduction in morbidity and mortality
- Sign in (before induction of anaesthesia) —> patient identity, consent, procedure, allergies, marked surgical site.
- Time out (before start of surgical intervention) —> team members introduce themselves, confirm patient’s name and procedure, surgical site infection bundle, VTE prophylaxis.
- Sign out (before any member of the team leaves the operating room) —> record name of procedure, instrument/swabs/sharp count, labelled specimens, any equipment problems? Any key concerns for patient recovery and management?
3
Q
Outline the role of surgical morbidity and mortality meetings (M&M)
A
- Used to aid to surgical training by taking time during each working week to discuss adverse outcomes.
- Education of all HCPs and hospitals to learn lessons from clinical outcomes and drive improvements in service delivery.
- Ensures quality.
4
Q
Apply the principles of informed consent
A
- Decision capacity.
- Documentation.
- Disclosure of risks/benefits and alternatives.
- Competency.
- Voluntary.
5
Q
Describe the elements necessary for mental capacity to give informed consent
A
- Disclosure - give all information necessary, including risks and benefits and what will happen if treatment is withdrawn.
- Capacity.
- Voluntariness - no external pressure (no coercion, manipulation, or undue influence).
6
Q
Check for mental capacity, and recognise when an individual doesn’t have capacity to give consent
A
- Mental Capacity Act 2005.
- Reasoning for questioning if a person has capacity: behaviours/circumstances, concerns have been raised by family or HCP, previously been diagnosed with a condition causing impairment of mind functioning.
- Assessing capacity: cannot assume capacity or discriminate, document decision with reasons.
- Two-stage test of capacity: Does the person have an impairment or disturbance in functioning of their mind or brain? Does the impairment or disturbance mean that the person is unable to make a specific decision when they need to (offer appropriate support to achieve this).
- Functional test, patient must: understand information, retain information, use and weigh information and communicate their decision.
7
Q
State the importance of written documentation, both for giving consent and documenting the information given to the patient and their supporters
A
IMPORTANCE OF DOCUMENTATION
- Shows reasoning for the clinical judgement made.
- Enable other clinicians important in the patients care to understand their situation.
- Shows timeline of patients journey.
- Shows proof of consultation/investigations/management (legal - covers doctors back).
8
Q
List the exceptional circumstances when you can rely on oral consent, and the need to document this
A
Exceptional circumstances when consent cannot be given:
- If patient is unconscious and in need of urgency life saving procedure.
- In an emergency you can rely on oral consent.
- Not possible to find out patients wishes.
- Least restrictive of patients future choices.
In the case of minor or routine investigations or treatments, if you are satisfied that the patient understands what you propose to do and why, it is usually enough to have oral or implied consent.
Document this!
9
Q
List the common risks associated with all surgery
A
- Anaesthesia complications: grogginess/confusion, N+V, headache, dizziness, fatigue, stroke, MI, brain damage, death, urinary retention, adverse reactions e.g. anaphylaxis.
- VTEs (DVT & PE).
- Post-operative lung infections.
- Wound infections.
- Bleeding/haemorrhage.
- Abdominal wall hernias.
- Pain.
- Neurological problems.
10
Q
Identify and discuss with patients the psychosocial effects of surgery including stomas
A
- Negatively impacts body image.
- Leaky bodies - stigma - ‘our bodies shouldn’t leak’.
- Odour associated.
- Not being bake to wear certain clothes/being embarrassed wearing certain clothes.
- Biographical shift - ‘will I be able to live as I used to?’
- Difficult to look in mirror for the first time.
- Concern about self care.
- Impact relationships - not feeling sexually desirable.
- Loss of control over body.
- Social isolation.
- Stigma that stoma is associated with disease.
- Depression/low mood.
11
Q
Outline the risk factors for chronic liver disease
A
- Excess alcohol consumption.
- Hepatitis B/C.
- High fat diet.
- Drugs e.g. paracetamol, steroids.
12
Q
Identify measures to address liver disease risk factors at individual and population level
A
INDIVIDUAL
- Not engage in dangerous activities e.g. unsafe sex, sharing needles, IVDU.
- Losing weight.
- Cutting down on alcohol.
- Up to date with vaccines.
SOCIETAL
- Education (schools, mass-media, doctors) on healthy diets, exercise and alcohol.
- Provide needle banks for safe drug use. Provision of clean needles.
- Free condoms.
- Better mental health treatment reducing alcohol and drug use.
- Blister packs for paracetamol and restricting amount a person can buy.
- Minimum pricing on alcohol.
- Sugar tax.
- Vaccinations for HCP and people travelling.
- Safe working environment to reduce needle stick injuries.
- Screening of blood transfusions to prevent hepatitis.
13
Q
Outline the epidemiology or breast cancer
A
- Most common cancer in UK.
- 1 in 8 women will develop breast cancer in their lives.
- Incidence is greatest in those aged 90+.
- 1% breast cancer cases are in males.
- 98% 5 year survival rate for stage 1.
- 25% 5 year survival rate for stage 4.
14
Q
Describe the organisation of breast screening services within the NHS
A
- Women aged 50-70 screened every 3 yrs. Those > 70 self-refer by talking to GP.
- Women < 50 have more dense breast tissue so mammogram is difficult to interpret.
- If genetic mutation —> yearly MRI scans (aged 20 for TP53 and aged 30 for BRCA1/2).
- Mammograms (X-rays) used to screen breast tissue. 2 X-rays of each breast (one from above and one from side) - 4 pictures in total.
- Results posted within 2 weeks.
- Abnormalities require further testing —> magnified mammogram or US of breast.
- Recall done via triple assessment.
CHALLENGES
- Overdiagnosis and overtreatment.
- Exposure to radiation.
- 75% uptake.
- Cost.
- Education about self-examination.
EFFECTIVENESS
- Digital mammography has a high sensitivity (97%) meaning it’s good at ruling breast cancer out. Low sensitivity (64.5%) meaning it’s not good at ruling cancer in.
15
Q
Outline the evidence on social patterns in delayed diagnosis for breast cancer in the UK
A
Risk factors associated with delayed presentation:
- Age.
- Low SES.
- Low education level.
- Initial symptoms weren’t a lump.
16
Q
Describe the factors that are associated with delayed presentation of breast symptoms in primary care
A
- Lack of knowledge on breast cancer symptoms.
- Embarraed of symptoms.
- Scared to have breasts examined.
- Symptoms are vague.
- Lack of education on self examination.
17
Q
Outline the role of family history in the risk of developing breast cancer and outline the options for prevention of breast cancer in those women at high risk of developing breast cancer due to a strong family history
A
- 5-10% breast cancers are genetic.
- Those with FHx usually more vigilant due to prior experiences with breast cancer.
- High risk: blood relatives, breast cancer before 50, breast and ovarian cancer FHx on same side, relative with triple -ve breast cancer, cancer in both breasts, man with breast cancer.
- Prevention: earlier screening, genetic testing.
18
Q
Which microorganisms are commonly implicated as causes of food poisoning?
A
- Incubation period: time from eating to symptom onset.
- Salmonella: incubation = 12-72 hrs, enteric fever (fever + abdominal pain) and enterocolitis, contaminated food, reservoir mainly eggs.
- E.coli: incubation = 12-48 hrs, due to contaminated food, 0157 cause HUS in children.
- Campylobacter: incubation = 48-96 hrs, commonest reported cause of infectious intestinal disease, due to undercooked meat and unpasteurised milk, reservoir of GIT of birds
- Bacillus cereus: incubation = 1-6 hrs, from undercooked re-heated rice.
- Staphylococcus aureus: incubation = 2-4 hrs, from contamination of previously cooked food with skin/nasal flora, toxin producing.
- Cryptosporidium: Protozoa, foreign travel, contaminated water (swimming pools, lakes, camping).
- Norovirus: most common cause of infectious gastroenteritis, N+V for 24 hrs, spread in enclosed environments e.g. hospitals and care homes.
- Clostridium perfingens: associated with slow-cooling and un-refrigerated storage, toxin producing.
19
Q
Outline the role of the doctor if they suspect a case of food poisoning
A
- Treat affected individuals: how to prevent spread, staying of work until 48 hrs symptom free, fluid replacement.
- Report to consultant/senior responsible.
- Notify local food safety authority: isolate and shut-down offending source.
20
Q
Which groups of individuals need to take special precautions regarding food poisoning?
A
- Elderly and children.
- Immunocompromised.
- IBD patients.
- Pregnant women.
- Individuals that work with food/restaurant business (food industry workers).
- Healthcare professionals working with immunocompromised.
21
Q
Outline the actions which may be required to control the outbreaks of food poisoning
A
- Identify and isolate source: person (school, workplace), place (events, restaurant), time (date and time of onset.
- Contact those who might be exposed.
- Collect data: number affected, symptoms, common factors, use questionnaires (limit recall bias).
- Food Hx.
- Environmental health officers visit restaurants and inspect premises. Take samples and swabs.
22
Q
Discuss the management of hospital outbreaks of infective diarrhoea
A
- Lift new cases after 72 hrs symptom free.
- Control of Infection Committee.
- Infection Control Officers (deal with day-day infection outbreaks).
- Decrease source of infectious agents (hand hygiene, prompt discharge, bare below elbows, aseptic techniques, clean equipment, flowers/cooked food/fruit gifts prohibited - potential reservoirs).
- Prevent transmission (Personal Protective Equipment, isolation, restricted ward access/visiting hours, ward closures - closed to visitors, new admissions and changing wards).
- Identify susceptible host and protect them.
23
Q
List the organisms commonly implicated in outbreaks within hospitals and healthcare seatings
A
- Norovirus.
- C.difficile (antibiotic use, watery diarrhoea).
- MRSA.
24
Q
Describe the approaches to reducing risk of outbreaks in hospitals
A
- Wash hands before and after you see a patient.
- Stay home if you’re ill.
- Only use antibiotics if appropriate.
- PPE.
- Get vaccinated e.g. flu, COVID.
- Use safe injection practised.
- Keep patients environment and equipment clean.
- Educate patients on infection prevention.
25
Define food poisoning
Gastroenteritis with infectious cause with presumed source being from food.
26
Define outbreak
Incident in which 2+ people, thought to have a common exposure, experience a similar illness or proven infection.
27
Describe the types of outbreak
- Common source: people exposed continuously or intermittently to a common source (infected water)
- Point source: sharp upward slope, all cases occurring in one incubation period.
- Propagation: spread via person to person, recurring increases, multiple waves, faecal-oral spread.
28
Describe some offences under the Food Safety Act 1990
- Sale of food rendered injurious to health, unfit for consumption, not of quality demanded by purchaser.
- Display of food with label falsely describing food or likely to mislead as to nature of substance / quality.
29
How might priorities vary internationally around prevention of chronic liver disease?
- In developing countries, infections (such as chronic viral hepatitis) are the leading cause of liver disease, however in developed countries, alcohol and metabolic syndrome causes more cases of liver disease.
- Therefore, different priorities in prevention.
- Varying available resources.
- Different financial and healthcare priorities.
30
Describe the organisation of cancer services in UK
EUROCARE REPORT
- Comparing 5 year cancer survival in patients across Europe.
- UK performed less well.
- Lower than Europe average for colorectal cancer mortality.
- Potential cause for poor performance: greater delay in pathway to diagnosis.
- Cancer survival rates in UK were one of the worst in Europe.
- Created Calman-Hine report as a consequence.
CALMAN-HINE 1995
- All patients should have access to uniformity of care.
- Recognise symptoms early.
- Patients, families and carers given clear information regarding treatment options and outcomes.
- Patient centred care.
- GP/primary care central to cancer care.
- Psychological needs of both carers and patients.
- Registration and monitoring - outcomes need to be documented.
CALMAN-HINE SOLUTIONS
- Primary care involved in early recognition and long-term care.
- Cancer units in district general hospitals: treat common cancers, diagnostic procedures, common surges, non-complex chemotherapy.
- Cancer centres: treat rare cancers, radiotherapy and complex chemotherapy.
- Importance of palliative care.
WHY ORGANISE LIKE THIS?
- Unites different commissioners e.g. health authorities, GP, hospitals, local authorities and voluntary sectors.
- Integrated care to deliver a holistic package.
- Targets resources where they’re needed most.
- MDT approach streamlines and coordinates care so it’s not fragmented, which leads to better outcomes. Team includes physicians, oncologists, radiologists, histopathologists, GP, specialist cancer nurses, physios, dietician and palliative care staff. Decide on management plan.
31
Define screening and why it’s important
- Systematic application of a test to identify individuals who are at greater risk of developing disease and therefore warrant further investigation, among those who haven’t yet sought medical attention. It is a form of secondary prevention.
- Earlier diagnosis leads to increased effectiveness of treatment and better outcomes.
32
Outline the National Screening Committee’s criteria for a good screening test in terms of condition, test, treatment and programme
- Condition: important health problem (common/severe), epidemiology and natural history understood, detectable risk factor/disease marker/asymptomatic period, all cost effective primary interventions should’ve been implemented as far as possible.
- Test: simple/safe/precise/validated, normal distribution of valves known and cut off agreed, agreed policy on further management of test +ve.
- Treatment: evidence based, effective intervention that leads to better outcomes if given earlier, cost-effective (lives saved and QALYs).
- Programme: effective at decreasing mortality and morbidity, benefit > harm, adequate resources, programme continually reviewed for quality assurance.
33
List the current national screening programmes
- Antenatal and newborn: sickle cell and thalassaemia, infectious diseases in pregnancy, Down’s syndrome and foetal anomaly US, newborn hearing, newborn and infant physical exam, newborn blood spot.
- Diabetic eye: annually to people with diabetes from the age of 12.
- Cervical cancer: women aged 25-49 every 3 yrs, 50-64 every 5 yrs.
- Breast screening: women aged 50-70 every 3 yrs.
- Bowel cancer: men and women aged 60-74 every 2 yrs.
- AAA: men aged 65.
34
Interpret sensitivity and specificity
- Sensitivity: rule out diagnosis.
- Specificity: rule in diagnosis.
35
Describe how changing disease prevalence influences NPV and PPV
If prevalence decreases, then PPV decreases and NPV increases.
36
What is the effect of changing prevalence on sensitivity and specificity?
Prevalence has no effect on sensitivity and specificity.
37
Describe the advantages and disadvantages of screening
ADVANTAGES
- Better patient outcomes (survival, may require less long-term therapy).
- Reassurance for those with negative results.
DISADVANTAGES
- Overdiagnosis - longer morbidity if prognosis is unaltered.
- Cost of resources.
- False reassurance with those with false negatives.
- Overtreatment: unnecessary investigations for false positives (waste of resources and induces anxiety in patient).
38
Describe the 3 biases of screening
- Lead-time: time between picking up disease via screening and the disease presenting symptoms. Survival appears longer as disease was diagnosed earlier. Prevented by measuring deaths prevented instead of survival.
- Length-time: more likely to detect a more slowly growing and treatable cancers causing an overestimation of survival duration and prognosis.
- Selection: well-educated individuals tend to worry and comply with screening programmes better. These individuals are often healthier and will therefore have better outcomes. I.e. not representative of general population.
39
Describe nudge, shove and smack techniques for addressing risk factors at an individual and population level
- Smacks: eliminating choice e.g. banning goods or services.
- Shoves: financial disincentives e.g. taxation, restricting choice.
- Nudges: provision of information, changes to environment, changes to default, use of norms.
40
What are the 5 most common cancers in UK?
1. Breast
2. Prostate
3. Lung
4. Bowel
5. Melanoma
41
What are the top five cancers with the highest mortality rate in the UK?
1. Lung
2. Bowel
3. Prostate
4. Breast
5. Pancreatic
42
Incidence vs prevalence
- Prevalence = the number of cases of a disease in a specific population at a particular timepoint or over a specified period of time.
- Incidence = the rate of new cases of a disease occurring in a specific population over a particular period of time.
H&S Year 3
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