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Yr1 Medicine PPS session

Thursday 8th June

1 - 3 pm

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Contents

The ABC of children’s medical ethics
Stress, illness and coping
Social aspects of nutrition
Social experience of chronic illness
Introduction to concepts of epidemiology and public health
Clinical trials for treatment of heart disease
Evidence based medicine and the role of chance
How many people die from asthma → Clinical iceberg of conditions

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The ABC’s of Children’s Ethics

Child: from birth to 18th birthday
Consent: this is required before all medical interventions except in the case of an emergency
Who can consent:
<16: with Gillick Competence can consent but can’t refuse treatment
> 16: can consent
Parents (with parental responsibility): biological mother can always consent. Biological father IF he is on birth certificate or written agreement w/ mother
Temporary carer
Court (can overrule both child, people with parental responsibility and temporary carers)
When is consent not required:
Emergencies
Abandonment by parents
Abuse by parents

- Consent required before all medical intervention except in case of emergency

Who can consent:

At the age of 16 there is a presumption that the patient is competent to give valid consent. Where

the child or young person lacks capacity, a person – or a local authority – with parental responsibility

can give consent on the patient’s behalf

- >16 child that has capacity can consent.

- <16 with gilick competence you can consent but can’t refuse treatment

- Parents (with parental responsibility:

- biological mother always

- biological father only has PR if hes on birth certificate or he has written agreement

with the mother.

- Step parents, local authority, adoption agency, legal guardian

- Temporary carer: does not have parental responsibility may do what is reasonable for the

purpose of safeguarding or promoting child's welfare

- Court: can authorise and/or refuse medical treatment for a child (and overrule both child,

people w parental responsibility, and temporary carers)

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The ABC’s of Children’s Ethics

Confidentiality in children:
> 16: treated as adults for the purposes of consent to treatment, so are also entitled to the same duty of confidence as adults
<16: if competent, have same duty of confidentiality. If not competent, then no.
Gillick’s competence (see notes)
Fraser guidelines (see notes)

Gillick’s competence:

Gillick's competence:

- whether a child is capable or not of giving consent depends on child's maturity and understanding

- must have sufficient maturity to understand what is involved

- parental rights only lasts until child reaches a sufficient understanding and intelligence to be making up their own mind

- can consent to treatment but cannot refuse

Fraser Guidelines:

Fraser guidelines:

- doctor could proceed to give advice and treatment (in regards to sexual health) if they are satisfied in the following criteria:

* patient can understand advice

* Dr cant persuade patient to inform parents, and are not allowed to go directly to parents

* patient is v. likely to have sexual intercourse with or without adequate contraception/advice

* patient's mental/physical health are likely to suffer

* advice/treatment is in patient's best interest

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Stress, Illness and Coping

Demand-control-support (DCS) Model:

Proposes that job strain is likely to occur when a person faces:

High job DEMAND and

Low job CONTROL and

Low social SUPPORT from colleagues/managers

Types of job control:

Decision authority vs skill discretion

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Social experience of chronic illness

7 things to remember
Adjustment to

Symptoms and incapacities of illness

Treatment procedures, hospital environment

Developing and maintaining

Relationships with healthcare providers

Relationships with family and friends

Preserving

A reaonable emotional balance

A satisfactory self image and competence

Preparing for an uncertain future

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SAQ

Eggsy is a 17 year old boy who has recently left college and spends much time with friends. His parents are divorced and his mother works long hours at a fast food restaurant from which she brings dinner every night.
Explain social factors that may affect Eggsy’s level of nutrition. (5 marks)

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Social Aspects of Nutrition

7 things to remember (CAPBESP)
Food Consumption
Individual Activity
Food Preparation
Individual Biology
Activity Environment
Social and cultural factors
Individual Psychology
Explanation in notes section.

Food consumption – availability of ready meals and fast food, eating in front of the TV

Individual activity – easy life, car ownership, long working hours, video games, all lead to reduced activity

Food preparation – longer working hours, less family meals and supervision in terms of nutrition and portions

Individual biology – genetic susceptibility, metabolism

Activity environment – less opportunities in cities, access to gym

Cultural social factors – mothers in middle class prioritise health value of food whereas lower social class mothers prioritise cost of food and preference of family. Lower social class families have higher levels of mortality. Rising demand for convenience food, social acceptability of fatness, food advertising

Individual psychology – food for compensation, depression can lead to eating as an outlet, eat quickly, eat until full

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Introduction to Epidemiology and Public Health

Epidemiology: the branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health.
Prevalence : number of people with disease at a particular period of time

Point or period

Incidence: number of new cases / total population at risk / time
Rates: things such as death and birth are measured as rates, as a proportion of the total population per year (usually)

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SAQ

a) Explain what is meant by ‘intention to treat analysis’ (3 marks)

b) What is the difference between ‘intention to treat analysis’ and ‘per protocol analysis’? (2 marks)

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Study types

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	Observational studies			Interventional studies
	Cross-sectional aka survey (descriptive)	Case control (analytical)	Cohort aka longitudinal (analytical)	Randomised control trials – parallel	RCT – cross-over
What is this?	Tests to see if people with certain exposure have higher disease prevalence	Patient group (have disease) and controlled group (do not have disease) and then assess for a particular exposure	To see if those with certain characteristics go on to develop disease. Prospective or retrospective	Participants are split into control group and intervention group, to assess direct causation.	Participants are switched halfway through study to avoid bias
Test involved	Prevalence: no of cases/no of people at a point in time	Odds ratio: odds of exposure in case/odds of exposure in control	Relative risk: risk of outcome in exposed/risk of outcome in not exposed
Advantages	Quick, cheap, easy to carry out	Cheap, quick, efficient for rare diseases, can investigate more than 1 risk factor	No recall bias, more than 1 disease can be measured, can calculate incidence	Can establish a very strong causation factor, useful in determining cures, can compare new to current treatment, randomisation removes bias
Disadvantages	Unable to measure incidence, not suitable for rare disease, reverse causality	Not suitable for diseases with rare exposure or several main risk factors , sensitive to recall bias	Can take a long time, expensive, observer effect, loss of follow up	Time consuming, expensive, sometimes unethical, assessor bias if not double blind

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Evidence Based Medicine and the Role of Chance

Null hypothesis (H0): the intervention has no effect on outcomes

If we gather enough evidence to reject the null hypothesis, then we have grounds to favour our alternative hypothesis which is often the research question. This is H1 (alternative hypothesis)

P value shows the likelihood of results being due to chance

Statistical significance = p<0.05
If significant we REJECT the null hypothesis

95% CI: this means we are 95% sure the true value lies within this range

If a ratio is used. This range cannot cross 1 otherwise we are not 95% sure.
If true values are used. This range cannot cross 0 otherwise we are not 95% sure.

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SAQ

A randomised control trial was conducted to compare the effectiveness of aspirin vs daily jogging at reducing cardiac events. The study measured the number of cardiac events over the next two years. The risk ratio was found to be 0.89, 95% CI (0.43 – 1.39) p = 0.1. What does this mean?

Null hypothesis should be accepted, data is significant
Null hypothesis should be rejected, data is significant
Null hypothesis should be accepted, data is insignificant
Null hypothesis should be rejected, data is insignificant
Must continue observation to produce more accurate results

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SAQ

As part of a recent study, patients with a mechanical heart valve were observed to assess the relationship between a lower level of anticoagulation and the risk of a haemorrhagic event. The control group continued on the standard level of anticoagulation, and the intervention group had a lower level of anticoagulation. Calculate:

The risk ratio
The absolute risk difference
Interpret both values

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How many people die from Asthma (PHEBP)

Main takeaway from this lecture: data sources

Lecturer focuses on their own research which is not relevant.

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Thank You

All the best for your exams!