This section is “categorized” under Clinical Medicine cf Primary Care – effectively it makes no difference the pages are still in the same place thanks to our close scrutiny of the RCGP syllabus and careful considerations of “best place to put everything”
There’s also of course a fair degree of overlap with other sections eg cervical screening — performing smears — colposcopy referrals go together in practice – so a degree of careful but not excessive cross referencing has been included to allow complete coverage of the syllabus whilst avoiding both repetition and too much jumping about
Full coverage but easy navigation is one of our main considerations – just look at the eBNF or Oxford handbooks on your ipad to see how hard that is to achieve in practice and how well or otherwise we might be doing
WHO Definition of Health 1948
a state of complete physical mental and social well being, not merely the abscence of disease and infirmity
Revised Definition of Health BMJ July 2011
Fixed risk factors
Modifiable Risk Factors
Australian Institute of Health and Welfare AIHW
|Cycle of change di clemente|
|Pre-contemplation||Not currently considering change:
“Ignorance is bliss”
|Validate lack of readiness
Clarify: decision is theirs
Encourage self-exploration, not action
Explain and personalize the risk
|Contemplation||Ambivalent about change: “Sitting on the fence”||Validate lack of readiness
Clarify: decision is theirs
Encourage evaluation of pros and cons of behavior change
Identify and promote new, positive outcome expectations
|Preparation||Some experience with change and are trying to change: “Testing the waters”
Planning to act within 1month
|Identify and assist in problem solving re: obstacles
Help patient identify social support
Verify that patient has underlying skills for behavior change
Encourage small initial steps
|Action||Practicing new behavior
|Focus on restructuring cues and social support
Bolster self-efficacy for dealing with obstacles
Combat feelings of loss and reiterate long-term benefits
|Maintenance||Continued commitment to sustaining new behavior||Plan for follow-up support
Reinforce internal rewards
Discuss coping with relapse
|Relapse||Resumption of old behaviors: “Fall from grace||Evaluate trigger for relapse
Reassess motivation and barriers
Plan stronger coping strategies
Ewles and Simnet Health Promotion Model
|Primary Secondary Tertiary Prevention|
|Primary Prevention||intervention before disease develops – immunisation sanitation accident prevention healthy lifestyle advice often population based|
|Secondary Prevention||preventing complications of disease by early recognition and effective management of established risk factors eg screening (would also include limiting spread of communicable diseases)|
|Tertiary Prevention||limiting progression severity complications and disabilities in established disease eg monitoring therapeutic interventions rehabilitation|
|2 months||DTaP/IPV(polio)/Hib (diphtheria, tetanus, pertussis (whooping cough), polio, and Haemophilus influenzae type b) – all-in-one injection, plus:
PCV (pneumococcal conjugate vaccine) – in a separate injection.
|3 months||DTaP/IPV(polio)/Hib (2nd dose), plus:
MenC (Meningitis C) – in a separate injection.
|4 months||DTaP/IPV(polio)/Hib (3rd dose), plus:
MenC (2nd dose) – in a separate injection, plus:
PCV (2nd dose) – in a separate injection.
|Between 12 and 13 months old||Hib/MenC (combined as one injection – 4th dose of Hib and 3rd dose of MenC).MMR (measles, mumps and rubella – combined as one injection), plus:
PCV (3rd dose) – in a separate injection.
|Around 3 years and 4 months||Pre-school booster of:
DTaP/IPV(polio) (diphtheria, tetanus, pertussis (whooping cough) and polio), plus:
MMR (second dose) – in a separate injection.
|Around 12-13 years (girls)||HPV (human papillomavirus) – three injections. The second injection is given 1-2 months after the first one. The third is given about six months after the first one.|
|Around 13-18 years||Td/IPV(polio) booster (combined injection of tetanus, low-dose diphtheria, and polio)|
|Wilsons Criteria Screening|
|1. The condition being screened for should be an important health problem|
|2. The natural history of the condition should be well understood|
|3. There should be a detectable early stage|
|4. Treatment at an early stage should be of more benefit than at a later stage|
|5. A suitable test should be devised for the early stage|
|6. The test should be acceptable|
|7. Intervals for repeating the test should be determined|
|8. Adequate health service provision should be made for the extra clinical workload resulting from screening|
|9. The risks, both physical and psychological, should be less than the benefits|
|10. The costs should be balanced against the benefits|
Aims to reduce the number incidence of invasive cervical cancer and its mortality. Said to prevent around 5000 deaths per year in the UK.
It does this by regularly screening all women at risk so that conditions which might otherwise develop into invasive cancer can be identified and treated
Most cases of cervical cancer appear to be related to the human papillomavirus (HPV) virus. It is thought that a woman must have been infected with HPV for about 7 years before it causes an abnormal smear result and 15 years All women aged 25-49 should be screened every 3 years and women aged between 50 and 64 should be screened every 5 years.
About one in 20 people in the UK will develop bowel cancer during their lifetime. It is the third most common cancer in the UK, and the second leading cause of cancer deaths, with over 16,000 people dying from it each year.
The NHS Bowel Cancer Screening Programme offers screening every two years to all men and women aged 60 to 69. People over 70 can request a screening kit by calling a freephone helpline when the programme reaches their area. GPs are not directly involved in the delivery of the NHS Bowel Cancer Screening Programme but they will be notified when invitations for bowel cancer screening are being sent out in their area. They will also receive a copy of the results letters sent to their patients.
How will the screening process work?
Men and women eligible for screening will receive an invitation letter explaining the programme and an information leaflet entitled Bowel Cancer Screening The Facts. About a week later, an FOB test kit will be sent out along with step-by-step instructions for completing the test at home and sending the samples to the hub laboratory. The test will then be processed and the results sent within two weeks.
What happens next?
Around 98 in 100 people will receive a normal result and will be returned to routine screening. They will be invited for bowel cancer screening every two years if still within the eligible age range.
Around 2 in 100 people will receive an abnormal result. They will be referred for further investigation and usually offered a colonoscopy.
Around 4 in 100 people may initially receive an unclear result which means that there was a slight suggestion of blood in the test sample. This could be caused by conditions other than cancer such as haemorrhoids (piles). An unclear result does not mean that cancer is present, but that the FOB test will need to be repeated. Most people who repeat the test will then go on to receive a normal result.
Between 5 and 10% of men over 65 years may have an asymptomatic aneurysm and 6000 men die each year from rupture (505) mortality
Ultrasound screening for aortic aneurysm has been shown to be of value in older men who are fit enough for surgery and who have an aneurysm of more than 5.5cm.
Diabetes Risk Scoring
Smoking is the number-one preventable cause of ill health (120000 deaths/year).
One in four adults in the UK smokes (13 million in total in the UK).
The cost to the NHS is £1500 million/year.
Cigarette smoking cessation and total and cause-specific mortality: A 22-year follow-up study NeLM Nov 2011
Pack Years = Packs smoked per day x years as a smoker (1 pack = 20 cigarettes)
eg a patient who has smoked 15 cigarettes a day for 40 years has a (15×40) / 20 = 30 pack year smoking history.
|Assessment of health risk based on BMI and waist circumference|
|Normal||Men < 94cm
|Overweight||Men 94- 102 cm
Women 80-88 cm
|BMI >25kg/m2||low risk|
|Obese Grade 1||Men >102cm
|Obese Grade 2||BMI >35kg/m2||High risk|
|Obese Grade 3||BMI >40kg/m2||Very high|
|Realistic goals for weight and waist loss|
|Short Term||1–4kg/month (2–8lb/month)||1–4cm/month (1–2 inches)|
|Medium term||10% of initial weight 12 weeks|
|Long term||10–20% of initial weight||<88cm (35 inches) for women <102cm (40 inches) for men|
Use in conjunction with lifestyle measures, set target 5% weight loss over 3 months.
better for those with high fat intake
ULowers fat absorption’:
TOS with or before meals.
NICE criteria: BMI >30 or >28 with co-morbidity (Type-2 OM, cholesterolaemia, hypertension) .
Continue>12 weeks only if 5% weight loss.
Can cause reduced absorption of fat-soluble vitamins (A, D, E, K) and reduced COCP efficacy.
CI: malabsorption, breastfeeding.
SEs: flatulence, diarrhoea.
appetite Suppressant better for those who cannot control eating
Licensed for maximum of 1 year.
NICE criteria: BMI >30 or >27 with co-morbidity.
Monitor BP and pulse 2 weekly for first 3 months, then monthly.
Stop if BP >145/90 or >10 mmHg diastolic BP rise or 10 bpm pulse rise at two consecutive visits.
Continue >12 weeks only if 5% weight loss.
SEs: dry mouth, abdominal pain, hypertension.
Rimonobant (Acomplia)Appetite Suprressant
NICE criteria: BMI >30 or >27 with co-morbidity.
CI: psychiatric illness.
SEs: dry mouth, abdominal pain, depression, anxiety.
Central abdominal obesity plus two of the following :
Waist higher than 102 cm males 88 cm females (Caucasions)
TG greater than 1.7mmmol/l
HDL lower than 0.9mmol/l in men or 1.1mmol/l in women
FPG greater than 5.6mmol/l
Hypertension Systolic BP higher than 130 Diastolic BP higher than 85
Glucose intolerance/hyperinsulinaemia Fating glucose > 5.6 (6.1?)
check latest definition for these values
|Abdominal Obesity||waist circ > 102 cm m > 88 cm f (Caucasions)|
|Hypertension||BP> > 130/85 mmHg|
|Atherogenic Dislipidaemia||TG>1.7 (1.69?) mmol HDL< 1.03 (1.04?) M or <1.29F|
NICE criteria for bariatric surgery
only if BMI >40 or >35 with co-morbidities and other measures conservative and medical measures have failed.
Patients must have exhausted all other nonsurgical measures >6m including intensive management in specialist clinic be fit for surgery including psychologically be seen in specialist clinic and committed to long term FU
BMI >35 kg/m2
BMI > 40 kg/m2
BMI > 50 kg/m2
Consider drug treatment only after dietary, exercise and behavioural approaches have been started and evaluated.
Children under 12
drug treatment is not generally recommended
prescribe only in exceptional circumstances, if there are severe life threatening co morbidities (such as sleep apnoea or raised intracranial pressure)
prescribing should be started and monitored only in specialist paediatric settings.
Children 12 and older
drug treatment is recommended only if there are physical co morbidities (such as orthopaedic problems or sleep apnoea) or severe psychological co morbidities
prescribing should be started by a specialist multidisciplinary team with experience of prescribing for this age group.
Consider only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity