Ph3

Front 1

T/F Healthcare system plays a major role in the health status of a population

Back 1

False.

there are many contributing factors to health: habits, genetics, socioeconomic status, environment, but surprisingly the healthcare system plays a very minor role in the health status of a population

Front 2

_______ is a major contributor to disparities in health

Give two particular examples (US).

Back 2

socioeconomic status

examples

- life expectancy at 16 is 16 years longer for white men and women living in the richest areas than African Americans living in the poorest (Geronimus, 2001)

- death rate in poorest regions of US exceeds that of Bangladesh

Front 3

T/F Life expectancy and GDP/capita are directly related up to a point, after which there are other contributing factors

Back 3

True

Front 4

List the findings that Emile Durkheim found regarding comparisons of suicide rates between different groups of individuals?

Back 4

Suicide rates greater in...

- Protestants compared to Catholics

- unmarried people compared to married

- soldiers compared to civilians

- in military officers compared to military privates

- in times of peace compared to times of war (because of improved nationalism)

Front 5

Who was the first person to point out the social contribution to disease by studying suicide rates?

Back 5

Emile Durkheim

Front 6

Sir Michael Marmot was responsible for the Whitewall study, what was the focus of the study?

Back 6

cardiac risk factors for workers of the civil service

Front 7

What are the findings of the Whitehall study of cardiac risk factors for workers of the British civil service?

Back 7

highest risk for dying from heart disease was a person’s rank

low rank > clerical > professional/executive> administrative

relative risks determined were significant even after adjusting for confounders

Front 8

Using Hill's criteria, how can we interpret the results of the Whitewall study?

Back 8

strong (large) relative risks tend to be causal

Whitehall Study showed a very probable causal relationship between rank and risk for heart disease death

the risk factor of rank was a better determinant of whether someone dies from heart disease than all cardiac risk factors combined

Front 9

Whitehall study.

Besides heart disease, what other two conditions show the relationship between lower rank and a higher risk of disease?

Back 9

stroke, cancer

Front 10

Compare the effect of per capita income on mortality with the effect of income inequality on mortality.

Back 10

effect of income inequality on mortality

more significant


than per capita income on mortality

note: your health/mortality is about where you are relative to those around you

Front 11

Moving from egalitarian populations to populations with extreme disparities in economic income has what impact on life expectancy?

Back 11

decreases LE

Front 12

Who made this claim?

"the decline in overall mortality in the 20th century was not a result of the advances of medicine; most of the decline occurred before modern medical care "

Back 12

McKinlay and McKinlay (US 1977) and McKeown (UK)

Front 13

McKinlay and McKinlay (US 1977) and McKeown (UK) claimed that the decline in overall mortality in the 20th century was due to what four factors?

Back 13

#1: improvement in the nutritional status of the population

#2: improvements in living environment and non-medical technology

#3 impact of hygiene and public health measures (improving water quality and sewage disposal)

#4: demographic changes (reduction in family size and parity)

Front 14

McKinlay and McKinlay did admit that there were 5 diseases that did benefit from medical intervention:

What are they?

Back 14

influenza,
pneumonia,
diphtheria,
whooping cough
poliomyelitis

vaccination resulted in 3.5% of the mortality decline

Front 15

What is the single biggest medical intervention that’s contributed to improvement in mortality?

Back 15

vaccinations

Front 16

Health Field Concept

Back 16

put money to improve factors which will have the biggest impact on the health of a population

- biological factors
- environment: defined as factors over which people don’t have control (air pollution, water pollution, etc)

- lifestyle factors: defined as factors over which people do have control (smoking, diet, exercise, alcohol intake, etc)

Front 17

Historically what would governments do to try to improve healthcare?

Back 17

put money into improving healthcare services (more hospitals, better training, new equipment, etc)

Front 18

According to the CDC in 2000, the ten great public health achievements are:

Back 18

vaccinations
heart disease and stroke
safer workplaces
family planning
safer and healthier foods
tobacco use
motor vehicle safety
mothers and babies
infectious disease
fluoridation of drinking water

Front 19

Why, as physicians, should we be good role models for health for our patients?

Back 19

studies have shown that pts of doctors who have healthy lifestyles are healthier than pts of doctors who do not have healthy lifestyles

Front 20

What are different BMI ranges?

Back 20

≤ 25 normal
25-29.9 overweight
30-34.9 Stage I obesity
35-39.9 Stage II obesity
≥ 40 Stage III obesity

Front 21

What are the two ways to calculate BMI?

Back 21

BMI = weight in kg/ (height in m)^2

BMI = 703 x weight in lbs/(height in in.)^2

Front 22

BMI: 23

Back 22

Normal

Front 23

BMI: 27

Back 23

Overweight

Front 24

BMI: 33

Back 24

Stage I Obesity

Front 25

BMI: 38

Back 25

Stage II Obesity

Front 26

BMI: 45

Back 26

Stage III Obesity

Front 27

NHANES studies show that the number of overweight or obese individuals in the US is rising

What were the findings?

Back 27

1/3 of the US population is obese (BMI>30.0)

- obesity is the second leading cause of preventable death (after smoking),

obesity will soon become the #1 leading cause of preventable death

Front 28

What are some conditions that follow obesity?

Back 28

hypertension, type 2 diabetes, coronary artery disease, stroke, and certain cancers

Front 29

What is the goal for obesity for Healthy People 2010?

Back 29

decrease obesity by 15%

Front 30

BMI must be interpreted carefully because it is intended for who?

Back 30

only for sedentary adults

Front 31

In children BMI tends to ____ fat

In elderly BMI tends to _____ fat

In body builders BMI tends to ____ fat

Back 31

overestimate fat in children and body builders

underestimate fat in elderly

Front 32

What is the recommended rate of body weight loss/wk for adults?

Back 32

lose <3 lbs per week

Front 33

What are the recommendations for duration and frequency of moderate exercise for weight loss?

Back 33

moderate intensity exercise for at least 30 minutes on 5 or more days per week (CDC)

Front 34

What are the recommendations for duration and frequency of intense exercise for weight loss?

Back 34

vigorous intensity exercise for at least 20 minutes on 3 or more days per week (Healthy People 2010)

Front 35

Public Health Efforts to Control Obesity

disclosure:

Back 35

nutritional labels

Front 36

Public Health Efforts to Control Obesity

Tort liability, what suits have been attempted?

Back 36

many have tried to sue fast food restaurants for making them fat; so far these lawsuits have been dismissed

Front 37

Public Health Efforts to Control Obesity

surveillance:

Back 37

some states want to make Type II diabetes reportable to the Health Department so that HbA1C levels can be monitored

Front 38

Public Health Efforts to Control Obesity

targeting children and adolescents: What is the biggest problem?

Back 38

the biggest problem in this population is soda

Front 39

Public Health Efforts to Control Obesity

tax unhealthy food:

Back 39

Canada has “sin taxes” for smoking, gas, and alcohol; some want to include unhealthy food in this tax

Front 40

Public Health Efforts to Control Obesity

school policies to reduce obesity in adolescents and children?

Back 40

more and more schools are banning soda and are developing healthier cafeteria menus

Front 41

Public Health Efforts to Control Obesity

the built environment:

Back 41

communities are greatly affected by the way they are designed- sidewalks encourage more walking

Front 42

Public Health Efforts to Control Obesity

food prohibitions:

Back 42

NYC has banned all trans fats

Front 43

USPSTF makes what general recommendations?

Back 43

recommendations only for hyperlipidemia and other coronary risk factors or diet-related chronic disease

general trend has been a movement from disease-specific recommendations to broad ones

Front 44

The Institute of Medicine gives what recommendations for macronutrient intake?

Back 44

- 20-35% calories from total fat

- 45-65% calories from carbohydrates

- 10-35% calories from protein

- 1 drink a day for women, 2 drinks a day for men

- minimize trans fats

Front 45

Give short descriptions of the three types of vaccines and and examples of each.

Back 45

- inactivated: microorganism is killed
- ex: influenza

- live attenuated: a weakened form of the microorganism that still activates the formation of Ab’s
- ex: rubella

- toxoid: a product of the microorganism you’re vaccinating against
- ex: tetanus

Front 46

What are the two types of vaccinations?

Back 46

- active: life-long immunity for the individual- this is what makes herd immunity possible

- passive: immunoglobulins given as treatment or prophylaxis following high risk exposures
- ex: a high risk rabies or tetanus exposure

Front 47

_______ the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine

Back 47

increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine

Front 48

______ the interval between vaccinations may interfere with Ab response and protection

Back 48

decreasing the interval between vaccinations may interfere with Ab response and protection

Front 49

Although vaccine reactions are generally rare, when they do occur you should report the incident to ______

Back 49

Vaccine Adverse Event Reporting System

Front 50

Vaccine contraindication:

Definition

Back 50

a condition in a recipient that greatly increases the chance of a serious adverse reaction

Front 51

Vaccine precaution:

Definition

Back 51

a condition in a recipient that might increase the chance or severity of an adverse reaction or might compromise the ability of the vaccine to produce immunity

Front 52

If there is a contraindication present, the vaccine ______ (decision)

Back 52

the vaccine should not be administered if there’s a contraindication

Front 53

If there is a precaution present, the vaccine ______ (decision)

Back 53

- administration should be decided on a case-by-case basis if there’s a precaution

Front 54

permanent contraindications to vaccination (2)

Back 54

- severe allergic reaction to a vaccine component or following a prior dose
- encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination (applies only to pertussis-containing vaccines)

Front 55

If a patient tells you that he had an allergic reaction to a vaccine how should you proceed?

Back 55

ask them what symptoms they experienced; often “allergic reaction” is used liberally and a vaccination is still recommended

Front 56

What types of vaccines are not recommended for pregnant women?

Back 56

- live vaccines should not be administered to women known to be pregnant

- HPV and Tdap vaccine should be deferred during pregnancy

Front 57

What types of vaccines are acceptable to give to pregnant women?

Back 57

in general, inactivated vaccines may be administered to pregnant women for whom they are indicated

Front 58

Describe three conditions that can cause a patient to be immunosuppressed.

Back 58

- disease: congenital immunodeficiency, leukemia or lymphoma, and generalized malignancy

- chemotherapy: alkylating agents, antimetabolites, and radiation

- the most common drugs that causes immunosuppression are corticosteroids

Front 59

Describe the corticosteroid dosing that can make a patient immunosuppressed and how this relates to the decision to vaccinate.

Back 59

20 mg or more per day of prednisone for more than 14 days does affect immunosuppression and possibly vaccination- do NOT give vaccine

- for pediatric populations: 2 mg/kg or more per day of prednisone for more than 14 days does affect immunosuppression and possibly vaccination- do NOT give vaccine

Front 60

T/F Corticosteroids administered topically or via aerosol do not prevent you from giving a vaccine

Back 60

True

- corticosteroids administered via aerosols or topically do NOT cause significant enough immunosuppression to affect vaccination

Front 61

T/F Short course corticosteroids (less than 14 days) does not result in immunosuppresion and vaccination is acceptable at this time.

Back 61

True

short courses of corticosteroids (less than 14 days) and alternate day corticoid treatments do NOT cause significant enough immunosuppression to affect vaccination

Front 62

Immunosuppressed individuals:

Live vaccine?

Inactivated vaccine? - caveats?

Back 62

live vaccines should not be administered to severely immunosuppressed persons

- inactivated vaccines are safe to use in immunosuppressed persons but the response to the vaccine may be decreased

Front 63

Immunosuppressed individuals:

What vaccinations are recommended for people who live around the immunosuppressed?

Back 63

receive MMR and varicella vaccines and annual influenza vaccination

Front 64

Should we vaccinate individuals with these conditions/situations?

- mild illness
- severe illness
- antimicrobial therapy
- disease exposure or convalescence
- pregnant or immunosuppressed person in the household
- breastfeeding
- preterm birth
- allergy to products not present in vaccine or allergy that’s not anaphylactic
- FH of adverse events
- tuberculin skin testing
- multiple vaccines

Back 64

Yes

these are not valid contraindications

Front 65

T/F It is fine to vaccinate during acute or mild illnesses

Back 65

True

- there’s no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions

- mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

Front 66

recommendation for routine vaccination up to age ___ was added to the other recommendations for the influenza vaccine

Back 66

18

Front 67

zoster vaccine is recommended for pts older than ___ years to prevent shingles

Back 67

60

Front 68

What are some measures of Vaccination Effectiveness for intervention and case-control studies?

Back 68

- for intervention study:
[AR(unvaccinated) – AR (vaccinated)] / AR (unvaccinated)
where AR = attack rate
- for case-control study: 1-OR where OR is odds ratio

Front 69

Coronary Artery Disease

non-modifiable risk factors :

Back 69

male gender, FH, and age

Front 70

Coronary Artery Disease

modifiable risk factors :

Back 70

cigarette smoking,
diabetes,
hypertension,
sedentary lifestyle,
excess weight,
hyperlipidemia, and
socioeconomic status

Front 71

CAD patients who are diagnosed after an incident must undergo ____ prevention

Back 71

tertiary

Front 72

The Framingham Risk Score serves what function as related to CAD?

Back 72

ID at risk individuals

- primary prevention of CAD begins with assessment of individual risk in asymptomatic individuals

Front 73

What must we consider when using Framingham Risk Scores?

Back 73

designed for adults > 20 yrs who do not have heart disease or diabetes

- scores come from data for white males because this was the Framingham cohort

Front 74

What hard CAD outcomes do the Framingham Risk Scores predict?

Back 74

score estimates as a percentage the 10-year risk for “hard” CAD outcomes (MI and coronary death)

Front 75

hard outcomes

Back 75

outcomes with reproducible clinical findings

Front 76

soft outcomes

Back 76

outcomes that are not reproducible clinically

Front 77

What factors are taken into account when calculating the Framingham Risk Score?

Back 77

age,
total cholesterol,
HDL cholesterol,
systolic BP,
treatment for hypertension, and cigarette smoking

Front 78

What is the target for treatment of patients with Coronary Artery Disease and why?

Back 78

LDL cholesterol remains the primary target of therapy because it is the risk factor we have the most data on

Front 79

_____ is not a factor in the Framingham Risk Score, but it can be used to provide additional information (it’s an independent predictor for CAD)

Back 79

BMI

Front 80

If a patient has both a high LDL and BMI what is true about the predicted FRS?

Back 80

The patient has a higher risk of CAD than predicted by the FRS

Front 81

What management is recommended for patients that have a FRS of

<10%

Back 81

Lifestyle modification

Front 82

What management is recommended for patients that have a FRS of

10-20%

Back 82

Test for atherosclerosis (CRP, stress testing, electron-beam CT, etc) followed by interventions as indicated

Front 83

What management is recommended for patients that have a FRS of

>20%

Back 83

Aggressive interventions (lipid-lowering agents, etc.)

Front 84

FRS 18%, 130 LDL, 40 BMI

What should you do?

Back 84

Most likely aggressive interventions.

Since the patient has high LDL and BMI, the risk for CAD is higher than predicted by FRS

Front 85

Describe the ranges for blood pressures in terms of being normotensive, prehypertensive, stage I hypertension, stage II hypertension

Back 85

normotensive <120/<80

prehypertensive 120-139/80-89

stage I hypertension 140-159/90-99

stage II hypertension >160/>100

(way to remember: normal 120/80
each range goes up 20/10.)

Front 86

T/F Lifestyle modification is recommended for all patients regardless of BP

Back 86

True

Front 87

T/F Normotensive and prehypertensive patients normally do not require antihypertensive drugs

Back 87

True

exception: patients with renal dysfunction could benefit from using an ACE I

Front 88

Hypertension I, what drug do you use?

Back 88

thiazide

Front 89

Hypertension II, what drugs do you use?

Back 89

thiazide and either a β-blocker or an ACE inhibitor

Front 90

What is the target BP for individuals who are hypertensive w/o diabetes or renal disease?

Back 90

<140/90

Front 91

What is the target BP for individuals with renal disease or diabetes?

Back 91

goal BP is < 130/80

Front 92

According to the AHA what are the normal values for

Total Cholesterol
HDL
LDL
Triglycerides

Back 92

- total cholesterol: less than 200 mg/dL

- HDL: 60 mg/dL or above

- LDL: less than 100 mg/dL

- triglycerides: less than 150 mg/dL

Front 93

Screening of lipids typically starts with what two measurements?

Back 93

Total cholesterol or HDL

pts do not need to fast before the test

Front 94

Patients with a total cholesterol > ____ need to have a fasting lipid profile

Back 94

>200

Front 95

Lipid screening should start at __ for men and __ for women

- levels should be rechecked every __ years

High risk individuals should be screened at ____

Back 95

35 yo for men
45 yo for women
- checked every 5 years

high risk individuals should be screened 20 yo

Front 96

What recommendations should be given to individuals who do not have symptomatic CAD?

Back 96

lifestyle modifications should be recommended before medications unless pt has symptomatic CAD

Front 97

Diabetics:
What is the recommended HgA1C?

What drug can reduce risk of nephropathy?

Back 97

- tight control of glucose reduces complications from diabetes

- goal is to keep HbA1C < 7%

- use of ACE inhibitors reduces risk of nephropathy

Front 98

What public health efforts have helped to reduce TB incidence?

Back 98

- greater institutional resources targeting high risk populations (health care workers)

- greater public health resources to ensure compliance with treatment

- directly observed therapy (DOT) lead to increase in compliance from 38% in 1993 to 78% in 2000

- reduced the number of people who would not finish their course of antibiotics which was responsible for antibiotic resistant TB

Front 99

5 challenges to TB control (CDC):

Back 99

1. prevalence of TB among foreign-born persons residing in US

2. delays in detecting and reporting cases of pulmonary TB

3. deficiencies in protecting contacts of persons with infectious TB and in preventing and responding to TB outbreaks

4. persistence of a substantial population of persons living in the US with latent TB (LTBI) who are at risk for progression to TB disease

5. maintaining clinical and public health expertise in an era of declining TB incidence (The Paradox of Public Health)

Front 100

3 core elements of TB control:

Back 100

1. case detection and management

2. contact investigations

3. targeted testing and treatment of LTBI

Front 101

Foreign Born individuals contribute to what percentage of TB?

Back 101

foreign-born persons account for 53% of TB cases in the US (Asian-born persons account for 29.4% alone)

Front 102

______ to _____% of persons with close exposure to a pt with pulmonary TB become infected

Back 102

- 30-40% of persons with close exposure to a pt with pulmonary TB become infected

Front 103

TB is transmitted by _____

Back 103

droplet nuclei

Front 104

What is true about LTBI individuals in terms of transmission and development of the disease?

Back 104

- these persons are asymptomatic and can’t transmit TB, but if put on immunosuppressive therapy, could become symptomatic and contagious

Front 105

Why is TB impossible to eradicate completely?

Back 105

this population of LTBI makes eradication of TB nearly impossible, but because most with LTBI are in the elderly population, as that generation dies, eradication may be possible

Front 106

Why isn't the BCG vaccine for TB recommended in the US?

Back 106

- the BCG vaccine (administered widely worldwide) is not recommended in the US because

it only gives partial protection and

it confounds the results of the TB skin test

(people with the BCG vaccine will have a positive skin test, not allowing us to determine if it’s because of the vaccine or because they actually have TB)

Front 107

TB Skin Testing with PPD for Healthcare Workers:

What is the procedure and why are we doing it this way?

Back 107

1. perform baseline testing on all new employees with potential for exposure

2. perform 2-step, baseline PPD tests on those with negative results on initial PPD

- 2 step testing is necessary due to the amnestic response: people with TB or the BCG vaccine may test negative at first but on the second test are positive

- knowing which pts have the BCG vaccine prevents interpretation of a positive TB test during a TB outbreak as having TB when the person really does not

3. perform periodic (usually annual) follow-up

4. perform test following suspected TB exposure and repeat at 12 weeks
+ PPD’s are evaluated for active disease and treated

Front 108

What is a positive PPD for an individual with one of these features?

- HIV infection or risk factors for HIV infection
- recent close contact with persons who have active TB
- fibrotic chest radiographs (consistent with healed TB)

Back 108

Positive PPD > 5 mm

Front 109

What is a positive PPD for an individual with one of these features?

- high risk groups: injection drug users; persons wit other medical conditions that increase risk of active TB; and children < 4 y.o.

- high prevalence groups: persons born in countries with high prevalence of TB; persons from medically underserved, low-income populations; and residents of long-term-care facilities

Back 109

Positive PPD > 10 mm

Front 110

What is a positive PPD for an individual with one of these features?

People not in high risk categories...

Back 110

Positive PPD > 15 mm

Front 111

What is the limitation of direct measurement of alcohol consumption?

Back 111

direct measurement (blood alcohol) only indicates recent consumption

Front 112

T/F Biochemical anomalies and work performance are not good measures of alcohol consumption

Back 112

True

- biochemical abnormalities are not sensitive (many alcoholics do not have abnormal biochemical results)
- performance measures (work) are not sensitive or specific; many alcoholics are very good at their jobs

Front 113

T/F Physician recommendations regarding alcohol use are particularly powerful, especially in male patients

Back 113

True

Front 114

What is the most sensitive and specific screening test for alcohol?

Back 114

CAGE questionnaire

Front 115

____ is most important for screening tests

Back 115

sensitivity

Front 116

____ increases as prevalence increases

Back 116

+ predicitive value

Front 117

T/F A screening tool is should be used if we can intervene after receiving a + result

Back 117

True

Front 118

In clinical practice most patients that undergo screening are _____ _____

Back 118

falsely +

Front 119

Screening

Requirements of the Disease (3)

Back 119

1. outcome must be serious and justify use of resources

2. earlier detection should mean improved outcome

3. prevalence must be sufficiently high to justify the test

Front 120

Screening

Requirements of the Test (3)

Back 120

1. quick, easy, and cheap (because will screen huge #’s of people)

2. safe and acceptable

3. a valid screening test must exist

Front 121

Bias
- 3 forms of bias can occur when evaluating screening tests

Back 121

1. volunteer bias: people who are screened tend to be healthier which makes the screening test look better than it actually is

2. lead time bias:all screening tests have a lead time so it’s important that the lead time be corrected for when comparing the effect of screening tests on time between diagnosis and mortality

- if lead time is not corrected for, a screening test will look better than it actually is

3. length bias: not all diseases follow the same natural history and screening works better for pts with milder forms of disease because there is more of a chance that screening will catch them before they develop symptoms and early therapy helps improve outcome

Front 122

volunteer bias: (in terms of screening)

Back 122

people who are screened tend to be healthier which makes the screening test look better than it actually is

Front 123

lead time bias: (in terms of screening

Back 123

- all screening tests have a lead time so it’s important that the lead time be corrected for when comparing the effect of screening tests on time between diagnosis and mortality

- if lead time is not corrected for, a screening test will look better than it actually is

Front 124

Length bias: (in terms of screening)

Back 124

not all diseases follow the same natural history and screening works better for pts with milder forms of disease because there is more of a chance that screening will catch them before they develop symptoms and early therapy helps improve outcome

Front 125

What are some characteristics of length bias in screening?

Back 125

- length bias is a form of Neyman bias: a cross-section always sees more forms of milder disease

- length bias is very difficult to quantify and control

Front 126

Why isn't lung cancer screening recommended?

Back 126

due to both lead-time bias and length bias

Front 127

Why do we see overdiagnosis in screening?

Back 127

- overdiagnosis appears as an extreme form of length bias

- in theory, screening may identify some cases you wouldn’t otherwise know about and such cases would die of other causes (therefore early screening and diagnosis does nothing to improve these pt’s outcomes)

Front 128

Screening

Requirements for Health Care System

Back 128

1. follow-up available for positive results

2. treatment available

3. how to handle findings

Front 129

Are regular checkups scheduled? Are they effective?

What considerations do we need to make on an individual basis?

Back 129

- is performed when a pt is seen for some other reason
- ex: 50 y.o. pt coming in for back pain should be asked about colonoscopy

- regular check-ups are not done for most pts

- exceptions: infants, elderly, and pregnant women should all have regular check-ups

- no trial has ever demonstrated that a periodic health examination leads to a reduction in mortality or morbidity
- must weigh risks and benefits with your pt
- ex: it may not be worth the risk to do a colonoscopy on a healthy 86 y.o. pt
- be selective
- special efforts needed for those with less access

Front 130

infants, elderly, and pregnant women should all have ____ check-ups

Back 130

regular

Front 131

community-level and policy interventions may be more effective than ____ ____

Back 131

regular checkups

Front 132

Why not screen all adult women with annual mammograms?

Back 132

- false positives:
- 86% in women >50
- 97% in women 40-49

- false negatives:
- 10% in women > 50
- 25% in women 40-49

Front 133

What are the three measures for recommendations by the USPSTF

Back 133

- internal validity of individual studies rated from I to III

- quality of evidence overall graded good, fair, or poor

- strength of recommendations from A to I

Front 134

USPSTF

Describe I-III categorization

Back 134

I: evidence obtained from at least 1 properly randomized controlled trial

II-1: evidence obtained from well-designed controlled trials without randomization

II-2: evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: evidence obtained from multiple time series with or without intervention; dramatic results in uncontrolled experiments (such as results of introduction of penicillin treatment in 1940s) could also be regarded as this type of evidence

III: opinions of respected authorities based on clinical experience, descriptive studies or case reports, or reports of expert committees

Front 135

USPSTF

Describe the good, fair, poor categorizations

Back 135

Good: evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes

Fair: evidence sufficient to determine effects on health outcomes but strength is limited by number, quality, or consistency of individual studies or consistency of individual studies, generalizability to routine practice, or indirect nature of evidence on health outcomes

Poor: evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in design or conduct, gaps in chain of evidence, or lack of information on important health outcomes

Front 136

USPSTF

Describe the A to I recommendations

Back 136

A: USPSTF strongly recommends that clinicians provide the service to eligible pts because it found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms

B: USPSTF recommends that clinicians provide the service to eligible pts because it found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms

C: USPSTF makes no recommendation for or against provision of the service because it found at least fair evidence that the service can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation

D: USPSTF recommends against providing the service to asymptomatic pts because if found at least fair evidence that the service is ineffective or that harms outweigh benefits

I: USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service because evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms can’t be determined

Front 137

ID the USPSTF category:

evidence obtained from at least 1 properly randomized controlled trial

Back 137

I

Front 138

ID the USPSTF category:

evidence obtained from well-designed controlled trials without randomization

evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

evidence obtained from multiple time series with or without intervention; dramatic results in uncontrolled experiments (such as results of introduction of penicillin treatment in 1940s) could also be regarded as this type of evidence

Back 138

II-1
II-2
II-3

Front 139

ID the USPSTF category:

opinions of respected authorities based on clinical experience, descriptive studies or case reports, or reports of expert committees

Back 139

III

Front 140

ID the USPSTF category:

evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes

Back 140

good

Front 141

ID the USPSTF category:

evidence sufficient to determine effects on health outcomes but strength is limited by number, quality, or consistency of individual studies or consistency of individual studies, generalizability to routine practice, or indirect nature of evidence on health outcomes

Back 141

fair

Front 142

ID the USPSTF category:

evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in design or conduct, gaps in chain of evidence, or lack of information on important health outcomes

Back 142

poor

Front 143

ID the USPSTF category:

USPSTF strongly recommends that clinicians provide the service to eligible pts because it found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms

Back 143

A - you should do it

Front 144

ID the USPSTF category:

recommends that clinicians provide the service to eligible pts because it found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms

Back 144

B - you should do it

Front 145

ID the USPSTF category:

USPSTF makes no recommendation for or against provision of the service because it found at least fair evidence that the service can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation

Back 145

C - you might consider doing it given the circumstances

Front 146

ID the USPSTF category:

USPSTF recommends against providing the service to asymptomatic pts because if found at least fair evidence that the service is ineffective or that harms outweigh benefits

Back 146

D - Not recommended

Front 147

ID the USPSTF category:

USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service because evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms can’t be determined

Back 147

I - you might consider this on a case-case basis

Front 148

Describe the transition of industrial medicine -> occupational and environmental health/medicine.

Back 148

industrial -> occupational -> occupational health -> occupational and environmental health/medicine

Front 149

Occupational health deals with the interface between medicine and work, taking into account the 2 mirrored aspects:

Back 149

1. work-related health effects: diseases or injuries that occur as a result of work

2. health-related work effects: diseases or injuries that affect work (but are not caused by the work)

Front 150

Define Injury

give an example based on acids

Back 150

- injury: one exposure or multiple in rapid succession
- ex: splash strong acid on hands leads to burn

Front 151

Define disease

give an example based on acids.

Back 151

disease: prolonged exposure
- ex: getting dilute acid on hands for 1 month leading to irritant dermatitis

Front 152

What is more common in the workplace, injury or disease?

Back 152

injury

Front 153

Define Environmental Health

Back 153

- impact of the environment on human health

- looks at air, water, food, etc
- follows logically from occupational health
- ex: air pollution, climate change, environmental lead, PCB exposure

Front 154

Occupational and environmental health focuses on _______ with emphasis on _______

Back 154

preventive, population-based feature

on dermatology, pulmonary medicine, musculoskeletal, and industrial (not pharmaceutical) toxicology

Front 155

T/F Occupational conditions are the same as their non-occupational counterparts

Back 155

True

Front 156

Occupationally-related conditions must be distinguished by _________

Back 156

history of occupational exposure

Front 157

Physician’s Role in Occupational Health

Back 157

1. prevention of work-related disease/injuries

2. identifying when a disease or injury is work-related

3. filing and managing workers’ compensation claims

4. advising on ability of pt to work (this applies to conditions that are either work-related or are not)

5. treating work-related medical conditions like back pain, skin disorders, lung disorders

Front 158

Classifying a condition as "work-related" means what probability of that it was actually work related?

Back 158

>50% (probable)

Front 159

Outcomes for a patient who has been off work can be improved by ____

Back 159

reducing the amount of time that they are off work

Front 160

What is the single most important predictor of a worker returning to work?

Back 160

time off work

by 6 months off work, 90% of people will never return to work

Front 161

Why is being off work detrimental to one's health in terms of social hierarchy?

Back 161

being off work puts pts at the bottom of the social hierarchy which is detrimental for their health

Front 162

What did Gordon Waddell describe in the occupational health paradigm and what are the consequences of being away from work?

Back 162

he found that long-term worklessness is one of the greatest risks to health for many reasons:

- loss of fitness, 2-3 x’s risk of poor health, depression, 2-3 x’s risk of mental illness, 20% excess deaths

- long-term worklessness is a greater risk than many “killer diseases”

- long-term worklessness is a greater risk than most dangerous jobs (construction, mining, etc)

- workless pts are trapped on benefits to retirement age and experience social exclusion and poverty

Front 163

Describe why re-employment of workers who have been of work is beneficial and also a caveat to this.

Back 163

re-employment improves physical and general health and well-being, improves mental health,

and the magnitude of improvement cause by re-employment is comparable to the harmful effects of losing a job but these improvements do depend on the quality and security of the re-employment

(if there’s a persisting risk of poor employment patterns and further unemployment, then improvements are minimal)

Front 164

What attitude of work is currently held and should be changed? Changed to what?

Back 164

work as a risk and potentially harmful to physical and mental health; therefore, they think that medical leave “protects” them

the opposite is really true: work is healthy, therapeutic, and the best form of rehab; this is why sending a pt back to work is preferred over sending a pt to rehab

Front 165

What factors contribute to 2/3 of individuals who are off work?

Back 165

less severe medical conditions: common mental health problems, musculoskeletal conditions, cardio-respiratory conditions

Front 166

What are some non-organic reasons that people are off work?

Back 166

- essentially whole people with what should be manageable health conditions

- high prevalence in working age population

- largely subjective: little or no disease or impairment

- multifactorial causation: work is usually only 1 of many contributory factors

- most episodes settle rapidly but are persistent and recurrent

- most people remain at work or return to work quite quickly

Front 167

Common health problems should be considered in a ______ context.

Also therapy should focus on _____ _____, not symptoms

Back 167

social

restoring function

Front 168

Describe the hierarchy of the prevention pyramid.

Back 168

substitution elimination (top)
engineering controls
administrative controls
Personal Protective Equipment (bottom)

Effectiveness is highest at top
Human involvement is lowest at top

Front 169

In terms of prevention, what are the least and most favorable methods?

Back 169

Least favorable: Personal Protective Equipment

Most favorable: substitution/elimination
(technology is second)

Front 170

T/F Chronic pain and depression go hand in hand

Back 170

True

- people who are depressed are more likely to have chronic pain

- people who have chronic pain are more likely to be depressed

Front 171

Martin’s Law

Back 171

“the difficulty negotiating a claim through a Worker’s Compensation system is inversely proportionate to the clinical severity of the condition”

- the milder the condition, the harder it is to get a claim negotiated

Front 172

Chronic pain syndrome (according to sanders, et. al)

Back 172

- pain of at least 3 months duration consistent with or out of proportion to physical findings

- progressive deterioration in ability to function at home, socially, and at work

- progressive increase in health care utilization (tests, expensive treatments, seeing many
specialists)

- mood disturbance
- clinically significant anger and hostility

Front 173

the AMA criteria for chronic pain syndrome (the 8 “D’s”)

Back 173

1. duration: >6 months

2. dramatization

3. diagnostic dilemma: physicians can’t agree on diagnosis

4. drugs: often pt has been prescribed opioids

5. depression

6. disuse: pts stop using parts of their body

7. dysfunction

8. dependence: pt becomes dependent on a social system for life functions

Front 174

What is the #1 reason for activity limitations?

Back 174

Musculoskeletal problems

Front 175

What are some of the statistics on WV on basis of lost work time and people staying off work after being injured?

Back 175

WV has the highest proportion of FT workers suffering lost injuries in the US (WV 48%, nationally 29%) and has the nation’s worst record for getting injured workers back on the job (in WV 1 in 3 workers stay off more than 1 month while the national average is 1 in 5 workers)

Front 176

T/F Even though most people recover from chronic pain, there still is a tremendous cost associated with chronic pain

Back 176

True

25% of lower back pain cases contribute to 90% of chronic pain costs

Front 177

acute back pain definition, general presentation.

Back 177

defined as pain less than 6-8 weeks in duration

- most pts with low back pain show no evidence of disease or structural abnormality (Waddell)
- 80-90% of low back pain episodes remit in 6-8 weeks

Front 178

What do you do for acute back pain, in the absence of red flags?

Back 178

do not do any tests (explain to the pt that no tests are indicated); tell the pt to continue regular activities and to take NSAIDs for the pain; the most important thing a physician can do for these pts is reassure them**

Front 179

Bed rest is not generally recommended for individuals with back pain. If you do suggest it, it should be for ____

Back 179

less than 3 days

Front 180

Acute back pain is self resolving (total resolution by week 8 in ____% of patients

100% of the remaining patients will still have problems ___ year after

Back 180

93%

1

Front 181

T/F Psychosocial factors are more important than biomedical factors in explaining why patients are still have back pain 1 year after wk 8 of acute back pain

Back 181

True

a prospective study by Burton et al showed that biomedical variables accounted for only 10% of disability at 1 year while psychosocial variables accounted for 59%
- catastrophizing alone accounted for 47% of disability

Front 182

What problems are associated with treating back pain problems?

Back 182

- a medical diagnosis is only useful when there’s an understanding of pathophysiology and therefore there are objective abnormalities which can be seen on clinical exam or investigations to make diagnosis and to monitor treatment and there is specific treatment

- the problems is that many musculoskeletal conditions are not amenable to traditional medical approach because physicians don’t agree on the causes, don’t agree on the appropriate tests/investigations, and don’t agree on the treatment

Front 183

T/F Medicalization of nonmedical problems is significant issue

Back 183

True

pharmaceutical companies have a significant impact on public perception of health problems

Front 184

more than ___% of the population is taking 1 or 2 prescription drugs; greater than____% is taking 3 or more

Back 184

more than 40% of the population is taking 1 or 2 prescription drugs; greater than 20% is taking 3 or more

Front 185

What does polypharmacy mean and is it harmful?

Back 185

- polypharmacy is when a pt is taking 5 or more drugs-

it has been shown that the adverse effects outweigh the benefit of treatment when a pt is taking this many medications

Front 186

What does Hadler say about patients with back pain in terms of psychosocial factors?

Back 186

psychosocial distress and that their pain is an indication of broader distress; pain is a maladaptive but unconscious response

Front 187

What does Cullen say are the 2 underlying social trends of back pain problems?

Back 187

1. pts expect to be asymptomatic all the time

2. the culture has shifted so that causes are externalized

Front 188

T/F Chronic back pain has a signficiant iatrogenic component

Back 188

True

Front 189

T/F More testing puts patients at ease as they know something is being done about their condition.

Back 189

False

tests increase patient fear (encouraging catastrophizing), perpetuate the myth of external cause with quick, passive, medical solution (discouraging pt from taking responsibility), create confusion due to irrelevant findings, and prolong doctor shopping which interferes with rehab

Front 190

What is the problem with physicians treating chronic back pain in a similar fashion as chronic malignant pain (opiod use)?

Back 190

increased dependency, unnecessary surgery

We don't actually know the cause of the back pain and we don't know of an effective treatment

Front 191

To what chronic back pain populations do physicians tend to prescribe more opiods?

Back 191

older
depressed
personality disorder
history of substance abuse

Front 192

What are some non-predicitive variables for physicians prescribing opiods over NSAIDS?

Back 192

medical variables like six-month average pain score, average numbers of encounters, and number of lumbar images

Front 193

Do we approach back pain at primary or secondary prevention level and what do we do?

Back 193

At the secondary level

- early identification and management of psychological, occupational, and socioeconomic factors in a pt’s life
- a clinical psychologist with expertise in pain can be very useful
- reassurance*
- avoid the biomedical model

Front 194

What are Waddell's signs for chronic back pain?

Back 194

- tenderness: superficial skin tender to light touch or nonanatomic deep tenderness not localized to 1 area

- simulation:
- axial loading pressure on skull of standing pt induces lower back pain when really there is no transfer of force
- rotation of shoulders and pelvis in same plane induces pain in lower back when this movement does not involve the lower back

- distraction: difference in straight leg raising in supine and sitting positions (in both positions, the tension on the nerve root is the same)

- regional:
- weakness in many muscle groups
- sensory loss in a stocking or glove distribution, nondermatomal

- overreaction: disproportionate facial or verbal expression

More than 1 sign indicates a nonbiological cause

Front 195

T/F Waddell's signs should not be used in elderly patients

Back 195

True

Front 196

- in working with chronic low back pain pts:

What should you keep in mind?

Back 196

- show humility: make sure that you
empathize with the pt and assure them that you believe that they’re in pain

- stop investigating

- wean off the medications

- work with appropriate multidisciplinary rehab facilities

- the physicians role should be peripheral (providing reassurance)

- emphasize function, not pain relief

- pt must move from passive to active role

- ***reassure the pt***

Front 197

What is the single biggest risk factor for having chronic back pain?

Back 197

Previous incident of having low back pain

Front 198

____ and _____ come into the highest contact with occupational exposure

Back 198

lungs and skin

Front 199

- in the US, workplaces are fairly safe so the most common occupational diseases are due to _______

Back 199

- in the US, workplaces are fairly safe so the most common occupational diseases are due to hypersensitivity

Front 200

hypersensitivity reactions do not follow the standard dose-response criteria

What does this mean?

Back 200

only a very small amount of exposure is needed to cause disease in a sensitized individual

- further episodes of exposure may pose a risk

- recurrent episodes may cause irreversible disease progression (like asthma)

- complete removal from the exposure may be necessary even if levels are below legal standards because regulatory standards are not designed to protect hypersensitive individuals

- personal protective equipment may not be an acceptable alternative

Front 201

Gell and Coombs Classification of allergic reactions: what are the four types?

Back 201

Type I: immediate hypersensitivity or anaphylaxis

Type II: cytotoxic reaction (rarely seen clinically)

Type III: immune complex reaction (rarely seen clinically)

Type IV: delayed-type or cell-mediated

Front 202

Type I: Immediate Hypersensitivity

Please describe it and give some examples.

Back 202

- examples of Type I reactions include allergic rhinitis, allergic conjunctivitis, asthma, urticaria, latex allergy, and anaphylaxis (sudden drop in BP accompanied by bronchoconstriction)

- atopy: a predisposition to getting Type I reactions

- Type I reactions are immediate and involve the release of pre-formed antibodies from mast cells

Front 203

atopy

Back 203

a predisposition to getting Type I reactions

Front 204

Type I reactions are ______ and involve the release of pre-formed antibodies from mast cells

Back 204

Type I reactions are immediate and involve the release of pre-formed antibodies from mast cells

Front 205

- the presence of ____ to a certain antigen indicates that the pt is sensitized to that antigen but not necessarily that the pt has the hypersensitivity reaction/disease

Back 205

IgE

- the presence of IgE to a certain antigen indicates that the pt is sensitized to that antigen but not necessarily that the pt has the hypersensitivity reaction/disease

Front 206

Type IV: Delayed or Cell-Mediated Immunity

Please describe it and give some examples

Back 206

- Type IV reactions are a result of the activation of T cells by macrophage antigen presentation; activated T cells release cytokines, recruiting more inflammatory cells to the site which results in a localized granulomatous inflammation

- symptoms usually develop in 48-72 hours post-exposure

- examples of Type IV reactions include contact allergic dermatitis, PPD testing, and Mantoux testing

- unlike Type I, Type IV reactions are not immediate and do not involve antibodies

Front 207

Patch tests are used to determine _____ allergic reactions

Back 207

Type IV

Front 208

- there’s no blood test for Type IV reactions because no ________ are involved

Back 208

- there’s no blood test for Type IV reactions because no immunoglobulins are involved

Front 209

Describe the two categories of functional lung disease and what disease fall into each.

Back 209

1. obstructive: this group includes asthma

2. restrictive: this group includes hypersensitivity pneumonitis (HP) and the pneumoconioses like coal worker’s pneumoconiosis (CWP or black lung), silicosis, asbestosis and other asbestos-related disease

Front 210

- spirometry

Describe what measurements you get out of performing one

Back 210

- FEV1 is Forced Expiratory Volume at 1 second which is the percent of air expired from the lungs in 1 second

- for a normal person, FEV1 should be 75-85%
- FVC is Forced Vital Capacity which is the volume of air a pt is maximally able to expire and it’s not linked to time

Front 211

obstructive lung disease

Describe what you see in terms of FEV1 and FVC

Back 211

there is a normal FVC (except in very advanced disease where it can be decreased) but a decreased FEV1

- obstructive lung disease is diagnosed based on the value of FEV1/FVC

- FEV1 is used to grade severity of obstruction by comparing the obtained FEV1 to a predicted FEV1 for the pt’s body size, age, etc

Front 212

in restrictive lung disease

Describe what you see in terms of FEV1 and FVC

Back 212

there is a normal FEV1 but a decreased FVC because of decreased volume capacity of the lungs
- restrictive lung diseases caused reduced lung volumes
- the FEV1/FVC ratio is normal (though it can be abnormal)

Front 213

What other conditions can lead to low performance on a spirometry test?

Back 213

poor effort and obesity (obtain similar results as in restrictive lung disease)

Front 214

spirometry

What kind of measurement do you obtain?

Back 214

only gives an indirect measure of lung volume so when abnormal spirometry result is obtained, then a direct measurement test should be conducted

Front 215

plethysmography

What kind of volume measurement do you obtain?

Back 215

is an example of a direct measurement of lung V- the pt is placed in a sealed chamber where the pressure differential is measured, independent of the pt’s effort- it is the most effective non-invasive, direct test for lung volume

Front 216

Asthma

What are some basic characteristics of asthma?

Back 216

- is variable airflow obstruction in response to certain agents

- is an episodic disorder but even between episodes, an inflammatory process is taking place, causing bronchial hyperreactivity

- is the most common occupational lung disease

- 10-15% of all asthma in adults is related to work

Front 217

Describe hypersensitivity in asthmatics.

Back 217

many asthmatics have specific triggers and react at very low doses (the Type I aspect of the disease) but these asthmatics also have non-specific bronchial hyperreactivity so that they may react to other agents (dust, smoke, cold air) more easily than non-asthmatics

Front 218

What must be true in order to diagnose work-related asthma?

Back 218

There has to be pre-existing asthma

Front 219

Differentiate between work-related asthma with and without latency.

Back 219

- asthma without latency (also called “irritant-induced asthma”) is caused by a direct irritant effect which occurs within 24 hours of exposure; no Type I reaction occurs in this type; it can last 3 years or longer

- asthma with latency is more common and involves sensitization over a period of months to years

Front 220

What does latency refer to when it pertains to asthma?

Back 220

time period between first exposure and when the pt actually develops asthma

Front 221

irritant-induced asthma or asthma without latency

What causes it?

Back 221

is caused by a high-level exposure to irritant gases like chlorine, ammonia, and acid mists

Front 222

T/F Individuals who experience asthma without latency are not allergic to the material which caused the asthma

Back 222

True

important to distinguish the type a person has because a person with asthma without latency is not allergic to the material that caused the asthma so they can be re-exposed to it after having recovered without being at greater danger than normal individuals (the same is not true for people with asthma with latency)

Front 223

asthma with latency is an ______ response

Back 223

asthma with latency is an allergic response

Front 224

What is the #1 cause of occupational asthma?

Back 224

Isocyanates

Front 225

What are the causes of asthma with latency?

Back 225

- causes include latex, large molecules (animal dander, detergent enzymes, flour proteins), isocyanates, and wood dust

Front 226

diagnosing occupational asthma involves 2 steps:

Back 226

1. diagnose the pt with asthma (a pt can’t have occupational asthma without first having asthma)

2. determine the relationship to work

Front 227

What does an environmental history entail?

Back 227

environmental history includes questions about household pets, carpets, home heating, smoking, and dust

Front 228

What does an occupational history entail?

Back 228

occupational history includes questions about exposures at work, symptoms worsening at work, etc.

Front 229

diagnosis of asthma involves _____ and ____

Back 229

spirometry and the methacholine challenge

Front 230

Patient potentially has asthma. The spirometry results indicate obstructive lung disease. How do you proceed?

Back 230

Give bronchodilator

obstruction will be reversed - diagnose as asthma

Front 231

Patient potentially has asthma. The spirometry results are normal. Are you done? How do you proceed

Back 231

no.

Do methacholine challenge

asthmatics will experience greater bronchoconstriction at lower concentrations than normal individuals

FEV1 is measured at first after giving pt a saline solution; then the pt is giving increasing levels of methacholine and FEV1 falls more and more; when pt’s FEV1 drops below 75% (compared to the original saline FEV1) the test is stopped ant the pt is given a bronchodilator

- the test is positive if the FEV1 falls 80% below baseline with less than 8 mg/mL methacholine

Front 232

Methacholine challenge test + result would be?

Back 232

PD20 <8 mg ml

Front 233

What is PD 20 and what can we use it for?

Back 233

is an artificial number that extrapolates what the dose would be when the FEV1 reaches 80%; as PD20 increases, the amount of bronchial hyperrreactivity decreases; PD20 can be used to follow a pt being treated for asthma

Front 234

What must you do in order to determine if the asthma is work-related?

Back 234

pt’s history:

peak flow monitoring can be used by the pt to monitor function at home

compare investigations when working and not working

if the PD20 increases or the spirometry normalizes, then work is the cause of the asthma

- you must be confident of the diagnosis before removing the pt from the workplace

Front 235

What pleural changes are possible in asbestos (a restrictive lung disease)?

Back 235

1. benign: plaques, thickening, effusions
- benign plaques are the most common radiographic finding after asbestos exposure

2. malignant: mesothelioma (any time a pt has mesothelioma, it’s always an occupational disease

Front 236

What parenchymal changes can occur due to asbestos exposure?

Back 236

1. “benign” fibrosis: asbestosis
2. malignant: lung cancer

Front 237

Smoking can aggravate _____ changes in patients with asbestos.

Back 237

parenchymal changes

Front 238

For lung cancer, ______ and asbestos has a synergistic effect

Back 238

smoking

Front 239

Asbestosis:

Back 239

there are small irregular opacities mostly in lower lung zones because the body clears materials in upper lung zones more efficiently

Front 240

Why is mortality from asbestos increasing despite the fact that it is no longer being used?

Back 240

There is a long induction period and it takes 20-30 years for the pneumoconiosis to develop

Front 241

Why does WV has the highest death rate for asbestos in the US?

Back 241

Because of the numerous steel mills

Front 242

Coal workers pneumoconiosis

What do we find?

How are levels of CWP changing in WV, KY and TE?

Back 242

there are small regular opacities in upper lung zones but no pleural changes

- recently levels in WV, KY, and TE are increasing for unknown reasons; in WV, more coal miners who have worked less than 10 years in the mine have more severe cases of CWP than those that were seen in life-long coal miners decades ago

Front 243

What is the major engineering control that is reducing the risk of CWP?

Back 243

water spraying in the mines to remove the dust

Front 244

Acute Silicosis:

What causes it?

Back 244

results from high level exposure to freshly generated crystalline silica

- it is not a fibrotic lung disease

- is rapidly fatal and involves fluid build-up in the lungs

Front 245

T/F Acute Silicosis is a fibrotic lung disease

Back 245

False

Front 246

What is considered the worst industrial accident in the US?

Back 246

the worst industrial accident in the US occurred during the digging of the tunnel at Gauley Bridge in the late 1920s where a minimum of 700 workers died within months of exposure (leading to acute silicosis)

Front 247

Chronic silicosis:

Describe what we find when we look at the lungs.

Back 247

there are small regular opacities in upper lung zones like in CWP but there may also be larger opacities- no pleural changes (like CWP)

- silica nodules are onion-shaped nodules that can be seen in the lungs of these pts

- pts with chronic silicosis have an increased risk of TB and fungal infections

Front 248

Describe the B reading classifications

Back 248

- b-readers classify opacities as regular (p, q, r seen in CWP or silicosis) or irregular (s, t, u seen in asbestosis)

- the letters represent opacities in increasing size as you go down the alphabet

- each reading is given a 2 level classification (like t/t or p/s)
- b-readers also classify grade profusion compared to standard films on a scale from 0 (normal) to 3 (greatest profusion)

Front 249

What is true about a patient who potentially has pneumoconiosis who doesn't end up having a B-reading?

Back 249

a pt is not eligible for benefits unless their x-ray has been read by a B-reader

Front 250

B-reading

What are B-readings and who can perform them?

Back 250

B-reading is a method to standardize chest x-ray readings of pts with pneumoconiosis; the standardized method was designed by the ILO (International Labor Organization)

- any physician that successfully passes the certification exam can be a B-reader (the exam only has a 50% pass rate)

Front 251

Hypersensitivity Pneumonitis (HP)

What kind of allergic reaction is it and what happens?

Back 251

- has elements of both type III and type IV hypersensitivity (mostly type IV)

- it’s a granulomatous disease which follows a spectrum from acute self-limited flu-like illness to chronic fibrotic lung disease

Front 252

there are 2 steps in the diagnosis of occupationally-related HP:

Back 252

1. diagnose HP

- observe decrease in FVC on pulmonary function test

- see diffuse granulomatous fibrosis on x-ray

- serological studies can be used because IgG is made (since there’s a type III element of the disease); when the lab does these studies, they do an “HP Panel” but you must tell them what kind of agents you think are most likely to be the cause so they can detect IgG’s made to those agents

2. determine relationship to work/environment

Front 253

If you patients have "recurrent flu-like symptoms" what do you need to suspect?

Back 253

The possibility of Hypersensitivity of Pneumonitis

Front 254

Why was litigation prior to Worker's compensation generally unsuccessful?

Back 254

the courts believed that you were agreeing to the risks of your job when you accepted a job and many lawyers used the argument of contributory negligence

Front 255

What problem arose when society moved from agrarian to industrial? How did this contribute into the development of WC?

Back 255

- as society moved from agrarian to urban/industrialized, work became more dangerous and families became dependent on the father as the sole source of income; thus, a single injury could condemn the family to poverty for the rest of their lives

- employers disliked litigation because the few cases that successfully sued the company would cost huge sums of money, often forcing the company into bankruptcy

WC would become the solution!

Front 256

When was WC developed and why was this a new step forward?

Back 256

- most WC systems were developed in the US by 1920

- WC was the first social insurance system to be developed in a country

Front 257

What does a "no fault" system mean?

Back 257

- a claim is accepted regardless of who is responsible for the injury
- this is an advantage because it saves money from hiring expensive lawyers for litigation

Front 258

What are the advantages and disadvantages of WC to the employer?

Back 258

- advantages for the employer: receive protection from lawsuits

- disadvantages for the employer: more successful claims than with litigation

Front 259

What are the advantages and disadvantages of WC to the employee?

Back 259

- advantages for the employee: easier acceptance of claim

- disadvantages for the employee: less money is received if claim is successful

Front 260

Who funds WC? How are these individuals managing the costs?

Back 260

- is funded by the employers

there is a “pooled risk”: risk is shared between companies

Front 261

premiums for WC are charged on payroll based on:

Back 261

- industry classification
- there is a “pooled risk”: risk is shared between companies

- claims experience
- incentive to improve workplace health and safety

Front 262

What are the state laws governing WC claims?

Back 262

claims be filed for conditions which, with a reasonable degree of medical certainty (>50% probability due to work):
- in the course of and
- as a result of performing normal job duties

- when in doubt (think there’s a 50% chance that the injury is due to work), give benefit to the worker

Front 263

WC includes aggravation but not exacerbation. What is aggravation?

Back 263

aggravation: pre-existing condition that work makes permanently worse

Front 264

WC includes aggravation but not exacerbation. What is exacerbation?

Back 264

exacerbation: a temporary flare-up of a pre-existing condition

Front 265

WC works on the "thin skull" principle. What does this mean?

Back 265

applies regardless of the presence of predisposing conditions (“thin skull principle”)

Front 266

Describe WC compensation claims in WV. #, % people who return to work before 4 days, % people who have lost time (>4 days)

Back 266

- in WV, there are 40,000 WC claims annually
- 80% of people who make claims return to work before 4 days
- 20% of people have lost time (>4 days)

- a small % of these have “delayed recovery” which accounts for most of the expenses of the system

Front 267

What is the role of the claims adjuster in regards to WC and should you feel troubled about this?

Back 267

- determines whether claim is acceptable

- authorizes all investigations and treatments

- determines level of benefits awarded

Yes because they're probably high school graduates!!

Front 268

To Whom do workers appeal decisions and what happens if the claim is accepted?

Back 268

Administrative Law Judge or State Supreme Court

- if claim is accepted and worker cannot return to work, then WC pays the worker temporary total disability (TTD) benefits which are 2/3 of their salary (for a maximum of 500 days)

Front 269

Describe the process from determination of TTD to Maximal Medical Improvement and finally to an impairment rating.

Back 269

Temporary Total Disability -> assessed by independent medical evaluation (IME) ->determined Maximal medical improvement,

- if the physician deems the worker to be MMI, then use AMA Guides to determine impairment rating

Front 270

Does the physician performing the independent medical evaluation in a WC treat the patient?

Back 270

no. only evaluates the patient's condition

Front 271

Describe how WC affects HIPAA and how we as physicians must act,

Back 271

by filing a claim, worker entitles all relevant parties (including the employer) to documents relevant to the claim
- WC overrides medical confidentiality laws (HIPAA)

- the worker must send all documentation concerning work-related injury or disease to WC and should include SSN, WC claim #, and date of injury

Physician: only medical information relevant to the injury needs to be sent

Front 272

- impairment:

Back 272

impairment: measure loss of structure or function
- is a medical determination by the physician
- describes the impact of the injury/disease on activities of daily living

Front 273

- disability:

Back 273

- disability: restriction in activities as a result of an impairment
- is not a medical determination
- instead is highly context specific

Front 274

There is _____ correlation between impairment and disability

Back 274

poor.

- workers with very high levels of impairment can have very low levels of disability and vice-versa

Example:
- impairment for a concert pianist and a teacher, both who lost their left arms at the shoulder, is the same, but their disabilities are different (disability is 100% for the pianist)

Front 275

permanent total disability (PTD):

Back 275

administrative decision that a person should not go back to work (determined by WC)

Front 276

Martin’s Law

Back 276

- “the difficulty negotiating a claim through WC is inversely proportionate to the clinical severity of the condition”
- it’s easier to assess the amputation of an arm than it is to assess back pain

Front 277

Why do some surgeons refuse to operate on patients who have a WC claim?

Back 277

studies show that WC can have an adverse effect on medical treatment

Front 278

What is the biggest work-related cause of disability?

Back 278

low back pain

Front 279

Why is the major driving cost of disability Temporary Total Disability (TTD)?

*Updated*

Back 279

TTD is a 2/3 payment of salary anywhere from 4 days to 500 days

Front 280

For low back pain what is the greatest source of cost?

Back 280

- most of the costs for low back pain are due to loss of days at work; though treatment costs are also increasing

Front 281

Public health is generally the responsibility of the ______ unless there are interstate implications

Back 281

state

Front 282

Federal administration of health falls mostly with this organization.

What is the distribution of funding that goes to healthcare (Medicare and Medicaid) and CDC?

Back 282

Department of Health and Human Services (DHHS)

- more than 80% of the DHHS’s budget was spent on healthcare (Medicare and Medicaid)

- only 0.5% of the budget goes to the CDC

Front 283

Identify the organization

- “to improve the quality, safety, efficiency, and effectiveness of health care for all Americans”

- responsibilities: research and policy in healthcare organization, financing, and quality

- recent focus has been on medical errors and quality

- organize National Guidline Clearinghouse (NGC) which is a centralized, searchable collection of health guidelines issued by any organization

Back 283

Agency for Healthcare Research and Quality (AHRQ)

Front 284

Who's mission statement is this?

- “. . . developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States”

Back 284

CDC

Front 285

Most public health activities fall under the _____

Back 285

CDC

Front 286

activities of the CDC:

Back 286

- directs control of infectious diseases at federal level
- works with states on disease surveillance and control
- provides information via Morbidity and Mortality Weekly Report (MMWR)
- immunization and other preventive programs
- research and training in public health
- research and training in occupation and environmental health (not regulatory functions- these fall under OSHA and the EPA)
- global disease control efforts

Front 287

regulatory functions of occupation and environmental health fall under the responsibility of what two organizations?

Back 287

OSHA -work
EPA - environment

Front 288

ID the organization

“. . . responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation”

Back 288

Food and Drug Administration (FDA)

Front 289

off label use:

Back 289

use for indication, dosage form, dose regimen, population use or other parameter no mentioned in the approved labeling
- FDA recognizes that such use by prescribers may be appropriate
- frequent in oncology and pediatrics

- limitations are on the manufacturer: can not promote off label uses

Front 290

black box warning:

Back 290

notification of a serious adverse effect

Front 291

What organization?

- “improving access to health care services for people who are uninsured, isolated, or medically vulnerable”
- ex: the WVU Positive Clinic, a treatment clinic for HIV/AIDS pts

Back 291

Health Resources and Services Administration (HRSA)

Front 292

What organization?

- “ . . . to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level”
- initiated in 1787

Back 292

Indian Health Service

Front 293

Describe NIH funding and its coveted grant. What has happened to funding since 2003?

Back 293

- intramural funding: funding for research within the NIH

- extramural funding: funding for research outside the NIH

- the R01 research grant includes both direct costs (what it costs to do the research) and indirect costs (money that goes to the university)

- NIH funding has steadily decreased since 2003

Front 294

Substance Abuse and Mental Health Services Administration (SAMHSA)

goals?

Back 294

- prevention and treatment of mental disorders and addictions

Front 295

Missions of Public Health

Back 295

1. promote physical and mental health
2. prevent disease, injury, and disability

Front 296

10 essential public health services

Back 296

evaluate
monitor health
Dx and investigate
Inform, educate, empower
Mobilize community partnerships
Develop policies
Enforce laws
Link to/Provide care
Assure competent workforce
research

Circle: Assessment -> policy development -> assurance

Front 297

Ottawa Charter for Health Promotion

What does the charter suggest?

Back 297

says we should change from “public health policy” to “healthy public policy” which stresses the importance of healthy communities and the new public health

Front 298

People 2010 has health promotion and disease control objectives

who coordinates it?

what are the main goals?

Back 298

- is coordinated by the federal government

- 2 broad goals:

1. increase the quality and years of healthy life

2. eliminate health disparities

- under the goals are 28 focus areas
- also identifies 10 leading health indicators and gives specific targets for each

Front 299

How is the healthcare system doing?

Are insurance and health compatibile?

Back 299

- insurance does not work for health

- for life insurance , you’re betting against the insurance company that you’re going to die before they think you will die
- the outcome is rare, tragic, and undesirable

Front 300

- “moral hazard”:

Back 300

"tragedy of the commons"

if a service is covered, then a person will use it independent of need
- ex: if an insurance covers massage therapy, many people are likely to use it even if they don’t need it

Front 301

Insurance Coverage:

Benefits of using employer coverage?

Back 301

employer-sponsored: company pays bulk of premium

Front 302

Insurance coverage:

Disadvantages of private insurance?

Back 302

individual buys own insurance from private insurance company

problems :
- enroll people on a case-by-case basis which is very expensive
- very high deductable

Front 303

Economists have shown that we pay _____ by not covering everyone than if we covered everyone

Back 303

more

Front 304

Medicare
- covers 3 groups of people:

Back 304

1. elderly (ages 65 +)
2. end-stage renal disease (regardless of age)
3. disability (per Social Security Administration)

Front 305

Medicare
- financed by (3)?

Back 305

1. federal income taxes
2. payroll taxes
3. out-of-pocket payments by enrollees because not all care is covered

Front 306

Medicare

administered by?

Back 306

Federal government

Front 307

Medicare

What is part A?

Back 307

Part A: hospital insurance

- automatic, no premium

- care in hospitals as an inpatient, skilled nursing facilities (not custodial or long-term care), hospice care, and some home health care

Front 308

Medicare

What is part B?

Back 308

Part B: supplemental insurance

- optional, premium in $96.40/month (2008)

- doctor’s services, outpatient hospital care, physical and occupational therapy, and some home health care

Front 309

Medicare

What is part C?

Back 309

Part C: managed care

- Part A, B, and D services provided by private, managed care organization approved by Medicare

Front 310

Medicare

What is part D?

Back 310

Part D: prescription drugs

Front 311

What are the advantages of Medicare?

Back 311

Advantage: spending growth generally slower than private insurance

Front 312

What are the disadvantages of Medicare?

Back 312

significant coverage gaps: most enrollees obtain supplemental insurance

- Medicare only covers 46% of costs for elderly

- costs are increasing partly due to the aging population but especially due to increased technology

Front 313

Medicaid

Who is covered?

Back 313

covers certain low-income individuals but not every poor person is covered

Front 314

Medicaid

Who administers it?

Back 314

state government
often out-sourced to non-government administrators

Front 315

Medicaid

Who funds it?

Back 315

financed jointly by the state and federal governments

Front 316

Medicaid

Advantages?

Back 316

Advantage: benefits are fairly comprehensive

Front 317

Medicaid

Disadvantages?

Back 317

Disadvantage: many providers won’t take care of Medicaid pts because the reimbursement levels are so low

Front 318

What is S-CHIP?

Back 318

State Children’s Health Insurance Program (S-CHIP)

- supplements Medicaid by covering low-income children who are ineligible for Medicaid

- administered and financed similarly to Medicaid

- similar problems to Medicaid:

- some providers refuse to accept S-CHIP due to low reimbursement rates
- under-enrollment
- eligibility varies by specific populations and states

Front 319

Veterans Health Administration

Back 319

- health benefits plan available to all veterans
- services delivered through VA health care facilities (“socialized medicine”)
- financed by the federal government

Front 320

Indian Health Service

Back 320

free healthcare for Native Indians and native Alaskans

Front 321

US HC System Compared to Other Countries in terms of cost

spending per capita? hospital care?

Back 321

- health care spending per capita in the US is twice that of other comparable countries

- hospital care is the single greatest expense and is constantly increasing

Americans spend more on out-of-pocket health care expenses

Front 322

At what ages are most of our medical expenses?

Back 322

- most of healthcare spending is spent on the final years (even months) of life

Front 323

What is currently the biggest problem in health financing?

Back 323

- the biggest problem is direct/out-of-pocket payments which are rapidly increasing

Front 324

Despite the greatest amount of spending on health, US has these problems:

IMR
Life expectancy
Deaths due to surgery mishaps, mistakes

Compare to other countries

Back 324

- the US has an infant mortality rate twice that of Japan’s
- WV’s infant mortality rate is the highest in US white populations

- the US has the lowest life expectancy after the UK compared to similar countries

- the US has the most deaths due to surgical or medical mishaps

- 1/3 of adults in the US experience duplicative or unnecessary care

Front 325

health care delivery in the US is described as a “cottage industry”:

what does this mean?

Back 325

it’s highly fragmented and there’s little communication

Front 326

We need improved _____ care

Back 326

Primary

Front 327

The Medical Home solution

Back 327

- a comprehensive method of primary care
- pt is assigned to a health care team who coordinates the pt’s care
- in this system, a pt’s hospitalization is seen as a failure
- largely driven by those who pay for health insurance

Front 328

Trauma:

- the trauma pt is an injured person who requires:

Back 328

- timely diagnosis and treatment
- of actual and potential injuries
- by a multidisciplinary team of health care professionals
- supported by the appropriate resources
- to diminish or eliminate the risk of death or permanent disability

Front 329

most trauma cases in the US are due to _______.

Back 329

most trauma cases in the US are due to motor-vehicle-related crashes

Front 330

the National Highway Traffic Safety Administration (NHTSA)’s mission is

Back 330

1. save lives
2. prevent injuries
3. reduce economic costs due to road traffic crashes

Front 331

trauma is extremely expensive:

What are some of the highest contributors to DALY for males?

Back 331

motor vehicle crashes, homicide, violence, and unintentional injuries accounted for more male DALY’s than ischemic heart disease (CDC and Harvard Study)

Front 332

the golden hour:

What is the concept? Concept problem?

Back 332

the period immediately following injury when resuscitation and definitive care improve outcome

- the problem with this concept: people who are dying at the site of the car crash due to failure of reaching them within the first hour of the injury have graver injuries and are still likely to die if EMS had reached them sooner

Front 333

Injury control

Prevention success depends on:

Back 333

Public policy – great for the public but not for the individual

Public acceptance

Public funding – funding will be pulled if the public does not approve (e.g. having the top speed limit as 55 mph)

Front 334

We need to look at trauma as a _____ and not a ______

Back 334

disease and not an accident

o Look for causes, treatment, & preventive measures
o Could save a country billions

Front 335

What are the injury control system

System components?

Back 335

Injury prevention
Prehospital care: starts with 911 – starts with activation; EMT/paramedics
Acute care facilities
Have to be able to safely not over-treat or overuse
Issue is using a CAT-scan for a splinter to avoid litigation
Put costs on someone else (not yourself as the doctor)
Post-hospital care

Front 336

What is needed to make sure that there is optimal use of the injury control system?

Back 336

Integration of resources
Seamless transition b/w phases of injury care

Front 337

Enhanced community health

What are some things that could help achieve this?

Back 337

Organized system, a friendly system

Injury prevention – best way to take care of injuries; don’t do it!!
Acute care
Rehabilitation
Identify risk factors
Develop interventions

Front 338

Activation of the injury control system is essential because ______

Back 338

there exists a chain of survival. Break one link -> harm to the patients overall outcome

Front 339

What are some issues with the injury control systems? Past incidents that have been particularly costly?

Back 339

o Most frequent trauma : 1-4 victims/incident (comes from the automobile)
o Greater # of victims may rapidly overwhelm routine resources – too quickly/too many to care for
Mass casualty
Natural
Man-made

• Intentional: War, terrorism
• Unintentional: Crane falling in NYC

Combination: New Orleans
• Huge costs in terms of deaths, disability, young/productive life years lost, money (12% of all medical spending)

Front 340

Describe components of the infrastructure of the injury control system.

Back 340

Leadership
Professional resources
Education & Advocacy
Information management
Finances
Research
Technology (On-Star, GPS, E911, CAN – automatic collision notification, etc.)
Disaster preparedness & response

Front 341

Describe the # of injury victims who benefited from evaluation/treatment in regional trauma centers

severity-adjusted national norm for patient cost?

also what are the total trauma center costs and losses

Back 341

o 678,000 injury victims in U.S. who benefit from evaluation/treatment in regional trauma center
o Severity-adjusted national norm for per patient costs in a trauma center is $14,896
o Total trauma center costs ~$10.1 billion
o Total trauma center losses ~$1 billion

Front 342

T/F Geographic location can effect patient access to injury control systems

Back 342

True

Front 343

T/F Funding challenges for trauma centers exist in both urban and rural areas

Back 343

True

Front 344

What are some future/current improvements to injury control systems?

Back 344

Automotive Telemetric/GPS
- Locate crashes, monitor vital signs, determine injury severity

Access
- ACN & wireless E911, video feeds, telemedicine, distance-based learning, patient simulator technologies

Front 345

Patient care is _______ driven, NOT protocol driven

Back 345

judgement

Front 346

Generally you need to focus on ABCs in trauma patients. What are they?

Back 346

Airway – basic skills first!
C-spine control

• Oxygen – keep pO2 > 95%
• Ventilation 12-20

Breathing

Circulation
- Control external hemorrhage

Front 347

What should we try to do in trauma situations?

Back 347

Appropriate triage & transport decisions

Field termination & resuscitative efforts
• Just because you have a CAT scan, doesn’t mean you have to use it

Front 348

• Basic SHOCK therapy

Back 348

Splint
Restore body temperature
Tourniquet
Haemostatic agents

Front 349

Injury transport

Goals

Back 349

10 minutes or less
Appropriate facility
Limited scene intervention

Front 350

As healthcare providers we must always be careful of _______

Back 350

burnout

If you can't take care of yourself - you won't be able to take care of the patient.

Front 351

• Golden Principles of trauma care

Back 351

Ensure safety of prehospital care providers & the patient

Assess the scene to determine need for additional resources

Recognize kinematics (but treat the patient)

Primary survey “Treat as you go”
ABC's

Warmed IV fluids
Medical hx
Secondary survey

The trauma patient owns him/herself, so we all work for the patient

“Primum Non Nocere” = first do no harm

Front 352

Shock:

When is it reversible? Irreversible?

Back 352

Reversible – The Golden Hour/Period

Irreversible
• Tissue Perfusion
• Mitochondrial death

Front 353

What are we trying to achieve in the golden hour?

Back 353

Gain access to the patient

Identify life-threatening injuries

Treat or stabilize life-threatening injuries
- Package
- Transport
• Closest APPROPRIATE facility
• Least amount of time

hemorrhage control & resuscitation

Front 354

What are some basic components of the injury control system?

Back 354

o Activation
Access

Asset integration

Existing resources

Future resources
o Anticipation
 Disaster Medicine

• At some point, need to triage (e.g. in the ER) – tough to say that you can save 3 in place of 1 if know he/she is dying

Integration of resources

Seamless transition b/w phases of injury care

Front 355

What are the significant reasons for the high costs of injuries?

Back 355

• Huge costs in terms of deaths, disability, young/productive life years lost, money (12% of all medical spending)

Front 356

Describe funding in injury control.

Back 356

Funding – Partial & intermittent
o Emergency Medical Services Systems Act of 1973
o Trauma Care Systems Planning & Development Act of 1990
o Congress failed to fund in 1995
o State & community funding
o Hospital & private funding by cost-shifting
o WV is @ high economic risk in regards to state trauma d/t:
Not a lot of money to go through it
Per capita income is not so good

Front 357

ID the Organization

- includes National Library of Medicine which maintains the Medline database

- “. . . the primary Federal agency for conducting and supporting medical research”

Back 357

NIH