3.07 - Difficult Circumstances - Pneumonia, Otitis Media, Indigenous Health

Front 1

What groups are especially recommended to take the influenza annual vaccination?

Back 1

a) >65 years
b) chornic debilitating disease sufferers
c) patients receiving immunosuppression
d) medical staff
e) those at risk of flu complications
e) nursing homes/chronic care residents

Front 2

Is the incidence for acute respiratory infection and pneumonia more or less in developing countries?

Back 2

More in developing countries

Front 3

t/f... the incidence of acute respiratory infection and pneumonia is higher at the extremities of life

Back 3

true

Front 4

When is the incidence of acute otitis media the highest?

Back 4

in the first two years of life, due to anatomical and immunity differences

Front 5

How does the incidence of acute otitis media vary with increased exposure to infection?

Back 5

increases

Front 6

t/f... breast-feeding protects against otitis media

Back 6

true

Front 7

How do bacteria attach to respiratory mucosa?

Back 7

By expressing adhesins which bind the organism to epithelial cell receptors

Front 8

What are the predominant bacterial pathogens that cause acute otitis media?

Back 8

Streptococcus pneumoniae
Haemophilus influenzae

Front 9

What is the definition of wasting?

Back 9

weight <3rd centile for age

Front 10

What is stunting?

Back 10

low height for age (<3rd centile)

Front 11

Which antimicrobial agents cause toxicity in patients with renal impairment?

Back 11

aminoglycosides, as it is not altered and normally is excreted unchanged in the urine, so with renal impairment the conecntration is increased in the body, causing possible toxicity

Front 12

What is the normal range of hearing?

Back 12

15 Hz to 15 kHz

Front 13

What is sensory hearing loss?

Back 13

loss of sensory structures (haircells) in the cochlea

Front 14

What is neural hearing loss?

Back 14

hearing loss due to auditory nerve dysfunction

Front 15

What is the definition of mild hearing loss?

Back 15

25 to 50 dBHL

Front 16

What is moderate hearing loss?

Back 16

50-70 dBHL

Front 17

What is severe hearing loss?

Back 17

70-90 dBHL

Front 18

What is profound hearing loss?

Back 18

deafness - 90dBHL or worse

Front 19

What is the commonest cause of mild hearing loss in children?

Back 19

otitis media with effusion

Front 20

What type of hearing loss is presbyacusis?

Back 20

high frequency sensory loss, occurs with age, 1/3 >65 have a loss that affects the speech range

Front 21

How long is the external acoustic meatus?

Back 21

one inch/2.5 cm

Front 22

Which part of the external acoustic meatus is cartilage?

Back 22

lateral part

Front 23

Is the medial part of the external acoustic meatus cartilage or bone?

Back 23

bone

Front 24

How is the external acoustic meatus oriented?

Back 24

concave anteriorly

Front 25

What nerve innervates the external acoustic meatus?

Back 25

V3
C2/3

Front 26

What is the innervation of the tympanic membrane?

Back 26

V3
X
IX - very sensitive

Front 27

Name the ossicles

Back 27

malleus, incus, stapes

Front 28

What is the function of the ossicles?

Back 28

transfer vibrations

Front 29

Name the muscles of the middle ear and their innervations

Back 29

Tensor tympani (V3)
Stapedius (VII)

Front 30

What is the function of the muscles of the middle ear?

Back 30

dampen vibrations

Front 31

What is responsible for transferring vibrations in the middle ear?

Back 31

ossicles

Front 32

What structures are affected in the case of hyperacusis?

Back 32

muscles of middle ear, no longer act to dampen vibrations therefore relatively quiet sounds can appear as very loud

Front 33

Name the two parts of the internal ear

Back 33

osseous and membranous labyrinth

Front 34

Which part of the internal ear contains perilymph?

Back 34

osseous labyrinth

Front 35

Which part of the internal ear contains endolymph?

Back 35

membranous labyrinth

Front 36

What is the most common pathogen causing pneumonia is infants aged 1-3 months?

Back 36

chlamydia trachomatis (RSV big too)

Front 37

What is the most common cause of pneumonia in children aged 1-24 months?

Back 37

RSV

Front 38

What is the most common cause of pneumonia in children aged 2-5 years?

Back 38

Respiratory viruses

Front 39

What is the most common cause of pneumonia in children aged 6-18 years?

Back 39

Mycoplasma pneumoniae

Front 40

What is the most common causative organism in severe pneumonia requiring admission to ICU?

Back 40

Streptococcus pneumoniae

Front 41

Which antibiotics are used against Streptococcus pneumoniae and Haemophilus influenza?

Back 41

beta lactams; quinolones in comorbidities/severe cases
(eg ampicillin (+) and 2nd generation cephalosporin (-); fluoroquinolone)

Front 42

Which antibiotics are used for atypical bacteria?

Back 42

macrolides (e.g. erythromycin)
tetracyclines
quinolones (e.g. fluoquinolone)

Front 43

What does legionella mimic?

Back 43

pneumococcal pneumonia

Front 44

What do beta-lactam antibiotics do?

Back 44

inhibit bacterial cell wall synthesis

Front 45

Why are beta lactams ineffective against mycoplasma?

Back 45

mycoplasmas do not have cell walls

Front 46

Which type of antibiotic does not have intracellular activity?

Back 46

aminoglycosides

Front 47

What do fluoroquinolones bind to?

Back 47

gyrase and topoisomerase inhibiting DNA replication and transcription.

Front 48

What are aminoglycosides most useful for?

Back 48

aerobic gram negative bacteria

Front 49

When is surgical treatment appropriate for otitis media with effusion?

Back 49

if present for over 6 weeks

Front 50

t/f... Scarring of tympanic membrane will cause a mild hearing loss

Back 50

false, scarring does not cause any hearing loss

Front 51

t/f... cholesteatoma causes erosion of bone

Back 51

true

Front 52

Why does hearing loss occur in cholesteatoma?

Back 52

erosion of ossicles

Front 53

What is otosclerosis?

Back 53

Growth of spongy bone which fixes stapes, causing conductive hearing loss.

Front 54

What type of hearing loss is caused by loss of hair cells within the inner ear?

Back 54

sensory hearing loss

Front 55

What is the incidence of hearing loss in children?

Back 55

approx 0.9/1000 live births and further 0.5/1000 deafened during childhood

Front 56

t/f... hearing can only be tested accurately after 9 months

Back 56

false, all children can be tested accurately at any age, and should be done as early as possible to maximise the benefit of any hearing devices

Front 57

Which organism causes 95% of lobar pneumonia?

Back 57

streptococcus pneumoniae

Front 58

What are the four stages of disease progression in pneumonia?

Back 58

congestion (boggy red, vascular engorgement)
red hepatisation (consolidated, pleurisy, neutrophils)
grey hepatisation (fibrosuppurative, dead rbc)
resolution (organisation, fibrous thickening)

Front 59

At what stage of pneumonia does neutrophil infiltration begin?

Back 59

congestion

Front 60

What pathological stage are neutrophils most numerous in pneumonia?

Back 60

red hepatisation

Front 61

At what stage of pneumonia do macrophages begin to play an important role?

Back 61

grey hepatisation

Front 62

What stage are macrophage numbers at their highest in pneumonia?

Back 62

during resolution

Front 63

Which white cell predominates in viral pneumonia?

Back 63

lymphocytes

Front 64

What are the common agents that cause community acquired pneumonia in people with normal immunity?

Back 64

streptococcal pneumonia
mycoplasma pneumonia
(chamydia psittaci in bird handlers, influenza can too, so can staphyloccossu secondary to influenza)

Front 65

What organisms which predispose to pneumonia commonly colonise in Australian Indigenous children within the first few weeks to months of life?

Back 65

Streptococcus pneumonia, haemophilus influenzae

Front 66

What is the best course of treatment for community acquired pneumonia?

Back 66

Beta lactams - Ampicillin (as treats s.pneumonia and 80% of h.influenzae) and second generation cephalosporins (treats the 20% h.influenzae that make penicillase).

If Legionella or mycoplasma is suspected, macrolides (e.g. erythromycin) or quinolones (e.g. fluroquinolone) should be used.

Front 67

t/f... recurrent infections can decrease a child's growth.

Back 67

true

Front 68

What disease is commonly associated with causing deafness in a child, when experienced by the mother in her 1st trimester?

Back 68

Rubella (German measles)

Front 69

What type of organisms are quinolones particularly useful for?

Back 69

Useful in intracellular pathogens such as legionella, mycoplasma, as it can enter cells easily via porins.

Front 70

How is pneumonia diagnosed?

Back 70

Full blood count - in s. pneumonia WC >15 x 10^9 (90% neutrophils), ESR >100 mm/h
Blood culture - confirm organism for treatment
CXR - confirms consolidation, may remain positive for weeks after cured though

Front 71

What groups of people are particularly at risk of peumoccocal infections?

Back 71

Asplenia
chronic disease
HIV
CSF leak
Indigenous Australians in areas of high MI incidence
>2 years old with nephrotic syndrome

Front 72

What are the management principles in someone presenting to the hospital with severe pneumonia?

Back 72

Prescribe antibiotics initially on empirical basis
Maintain arterial O2 >90%
Reverse any complications e.g. shock, respiratory failure
If not responding to treatment, investigate with sputum and blood cultures to ascertain pathogen and to direct antibiotic use.

Front 73

What is conductive hearing loss?

Back 73

Loss of conduction of sound to the cochlea due to a problem in the outer or middle ear

Front 74

What can cause conductive hearing loss?

Back 74

Otitis Media with Effusion (OME, 'glue ear'), tympanic membrane perforation, otosclerosis

Front 75

What can cause sensory hearing loss?

Back 75

presbyacusis (age related hearing loss, usually first in higher frequencies)
noise induced hearing loss
menier's disease (disorder of the inner ear most likely due to lymph fluid mixing, characterised by vertigo, tinnitus and hearing loss)

Front 76

What is an example of neural hearing loss?

Back 76

Acoustic neuroma (benign tumour between brain and inner ear, internal acoustic meatus)

Front 77

Why is it so important to minimise hearing deficits in young children?

Back 77

Can lead to inattention, poor performance in school, socially inconvenient, can prevent acquisition of speech and communication

Front 78

What is the most common cause of hearing loss in:a) children b) adults

Back 78

a) otits media with effusion 'glue ear'
b) Noise induced hearing loss, presbyacusis
also middle ear disease, otosclerosis, meniere's disease, autoimmune hearing loss, Cogan's syndrome, ototoxic medications, acoustic neuroma

Front 79

What how long must you listen to the following loudness of noises to induce hearing loss? a) 90dBA b) 92 dBA c) 96 dBA

Back 79

a) 8 hours
b) 4 hours
c) 2 hours

Front 80

What are the advantages of giving a live vaccine over a non-live vaccine?

Back 80

Mimi natural infection, amplify to produce a large antigenic stimulus, induce, T and B lymphocyte responses, longer lasting protection with less need for boosters

Front 81

What are some examples of Live vaccines?

Back 81

MMR, OPV, Varicella, rotavirus

Front 82

What are some examples of non-live vaccines?

Back 82

IPV, Hib, Hep B, DTPa

Front 83

What is the advantage of using inactivated/killed vaccines?

Back 83

No risk of infection from the vaccine to immunocompromised individuals

Front 84

What is the disadvantage of using killed, inactivated vaccines?

Back 84

Less effective than live, several doses needed for long term protection as well as boosters, limited production capacity and higher price (as don't self-replicate), B cell response is mounted more so than T cell

Front 85

What re the disadvantages of using live vaccines?

Back 85

Retain pathogenicity, may revert to virulence, may not be able to be use in immunocompromised patients, need to be stored and transported in cool conditions (otherwise lose potency)

Front 86

Which Ig is seen in the primary immune response?

Back 86

IgM, IgG lags behind and is used more in the secondary immune response on re-exposure

Front 87

What influences timing and number of vaccines needed in infants?

Back 87

type of vaccine, maternal Ab, maturity of the immune system, disease incidence and prevalence

Front 88

How do booster doses of vaccines work?

Back 88

The replenish memory cells by re-stimulation so that they are prepared to fight the real infection. Must be given after at least a month of previous exposure in order to allow time for naive lymphocytes to divide into memory cells.

Front 89

What can enhance immunogenicity of a vaccine?

Back 89

Needed especially for non-live vaccines:
Repeated doses
Adjuvants - material to enhance immune response by delay release or increasing cellular uptake of Ag
Conjugation - linking Ag to a carrier protein which increases T cell stimulation

Front 90

How many people need to be immunised to produce herd immunity?

Back 90

To protect the immunised people and those who cannot be immunised (very young, sick), 90-95% of the population needs to be immunised.

Front 91

What is the challenge with regard to the general community's attitude to vaccine adverse event claims?

Back 91

Adverse event claims are usually made due to a temporal association between event and vaccination, and are anecdotal and as such are compelling and immediately newsworthy.
Scientific evaluations are complex, lengthy difficult to understand and are not communicated well to the public.

Front 92

What are the phases in Vaccine development?

Back 92

I - safety and immunogenicity
II - Immunogenicity and safety
III - efficacy
IV - effectiveness and safety

Front 93

What 2 antibiotic types are most effective at treating intracellular obligate bacteria?

Back 93

Macrolide (erythromycin, azithromycin) Quinolones

Front 94

How do bacteria resist Macrolides?

Back 94

efflux pump

Front 95

What bacteria types are aminoglycosides most useful for?

Back 95

aerobic gram negatives

Front 96

What are 3 types of drugs used to treat systemic fungal diseases?

Back 96

Polyenes (effect membrane integrity)
Azoles (inhibit biosynthesis)
Echinocandins (inhibit glucan synthesis in walls)

Front 97

What are problems with sputum examination?

Back 97

not suitable for young children, <30% coughs are non-productive, <30% patients have already been treated with antibiotics, presence of bacteria doesn't mean it is the causative agent

Front 98

How do you tell if a agent is just colonising, or causing an infection?

Back 98

Hard to tell, if you get sputum tests, does not necessarily mean that is the cause e.g. s. pneumoniae and h. influenzae. Rarer causes of pneumoniae are more indicative of the pathogen cause, getting from a usually sterile site will also tell you it is a causative agent.

Front 99

What is the benefit of getting samples from sterile sites for determining pathogen?

Back 99

most likely the cause of the pneumoniae, indicate severe pneumonia, can do pcr to amplify results better than with sputum cultures

Front 100

What is the best way to detect respiratory viruses?

Back 100

mostly done in children includes
nasopharyngeal aspirate, swab, nasal washing, then PCR

Front 101

What is an issue with diagnosing pathogen from pcr?

Back 101

mostly used in children, false positiives can occur due to amplication, multiple infections can be identified

Front 102

When is testing for causative agents of pneumonia not important?

Back 102

routine community acquired instances of pneumonia

Front 103

When is microbiological testing to identify the causative agent of pneumonia important?

Back 103

severe or non-responsive cases (ICU, immuncompromised, hospital setting)
organism - virus identification to stop AB, and to ascertain antimicrobial sensitivity e.g. TB, s.aureus

Front 104

How do you distinguish bacterial from viral pneumonia?

Back 104

Virus usually- child <5, slow onset usually, wheezing and rhinitis present, low sc count, low acute phase reactants, diffuse CXR, slow/non-responsive to AB

Bacterial - adults, rapid onset usually, high fever high RR, high WC, high acute phase reactants, very dense infiltrate on CXR, rapid response to antibiotics

Front 105

Approximately how many children deaths from pneumonia are in indigenous children?

Back 105

50%

Front 106

Incidence of adult pneumonia in <55 and >85 year groups.

Back 106

10/100 000 in <55 - 1000/100 000 in >85

Front 107

What are the 2 major pathogens seen in pneumonia patients <60 without coexisting disease?

Back 107

s. pneumoniae, m. pneumoniae

Front 108

What are the 2 major pathogens seen in pneumonia patients >60 or with comorbidities?

Back 108

s. pneumoniae, respiratory viruses (gram - and staph also begin to be seen)

Front 109

What are the 2 major pathogens in hospitalised pneumonia patients?

Back 109

s.pneumoniae, h. influenzae (multiple bugs, legionella, s.aureus important too - may need vancomycin and macrolide)

Front 110

What are the 2 major pathogens in ICU pneumonia patients?

Back 110

s.pneumoniae, legionella, aerobic gram -

Front 111

When was the referendum made to overturn the 2 instances of exclusionary references to australian indigenous people in the 1901 Constitution?

Back 111

1967, with 90.77% voiting for it.

Front 112

When was the first aboriginal medical service set up?

Back 112

1971 in Refern

Front 113

What is the 'Bringing them home' report?

Back 113

Report in May 1997 about inquiry into stolen generation

Front 114

Did being taken from their families benefit indigenous children in terms of education and employment?

Back 114

No, similar levels of education and employment between stolen generation and non-stolen.

Front 115

Who was Eddie Murray?

Back 115

21 yo aboriginal man put in custody for being drunk in 1981, found dead hanging in cell. Initiated the royal commission into aboriginal deaths in custody.